Entrepreneurship after EM Residency: The Ketamine Clinic for the Emergency Physician

Research has revealed ketamine’s wide non-anesthetic applications, giving providers from various disciplines an opportunity to heal more while also allowing them to build their healthcare practices simultaneously.


Emergency physicians are competent ketamine providers because of their mastery of the drug’s multiple actions and medical uses. The American College of Emergency Physicians (ACEP) projects a surplus of emergency medicine doctors by 2030 (Marco et al., 2021). If you’re in this specialty and mulling the soon-to-be shortage of hospital jobs for ER physicians, think of owning a ketamine clinic as a viable Plan B.

Read on as we explain why running a ketamine clinic is a job for the emergency physician.


What Advantages Do Emergency Medicine Physicians Have as Ketamine Providers?


Ketamine is as much a mainstay drug in the emergency department as it is in the OR, and this medication is deeply embedded in the emergency physician’s practice. If you are in this field, then you have unique advantages as a ketamine provider.


Emergency Medicine Prepares Doctors to Administer Ketamine in Various Clinical Settings


Emergency medicine specialists are trained to use this NMDA receptor blocker in many situations.

  • Across age groups—emergency physicians are taught to administer ketamine to adults and children when appropriate (Domany et al., 2020; Holloway et al., 2000; Bhatt et al., 2017).

  • Over a wide dose range—a low-dose ketamine infusion lets emergency medicine doctors treat physical and psychic pain (Motov et al., 2018; Karlow et al., 2018; ACEP, 2017). High ketamine concentrations facilitate painful procedures and control status epilepticus in the emergency department (Kannikeswaran et al., 2016; Dilip et al., 2021; Fang & Wang, 2015).

  • Using different routes of administration—emergency physicians can give the drug in many ways, particularly those proven effective by studies. They include the intravenous, intramuscular, and intranasal routes (ACEP, 2017; Motov et al., 2018; Shrestha et al., 2016; Shimonovich et al., 2016).

  • Prehospital and in-hospital—emergency medicine physicians are trained to give ketamine for crises outside and inside the hospital (Tran et al., 2014).


Expertise in the drug’s vast clinical effects gives emergency medicine-trained doctors a solid edge as ketamine providers.


Emergency Physicians Skillfully Deal with Ketamine’s Side Effects


We explained in a previous article that ketamine’s neurocognitive side effects are dose-dependent. Souza-Marques and colleagues found that it does not significantly impair cognition when given to mood disorder patients at subanesthetic levels (Souza-Marques et al., 2021).


However, the drug still has a risk of causing acute but often minor cardiorespiratory side effects even at doses as low as 0.3 mg/kg (Beaudoin et al., 2014). Note that IV ketamine’s typical antidepressant dose is 0.5 mg/kg (Zarate et al., 2006).


Side effects are unavoidable in nearly every available medical therapy, even more so with a drug like ketamine, which acts potently on various signaling systems. Although highly unlikely, no one can rule out the possibility of severe reactions occurring during a 40-minute IV infusion. That is why an emergency physician’s advanced intubation and cardiac life support skills can come in handy at ketamine centers.


Emergency Physicians Administer Ketamine for a Variety of Clinical Conditions


ED patients come in all shapes and sizes. For example:

  • The thin 35-year-old female who lost a loved one to COVID-19. She now has suicidal thoughts.

  • The cyanotic 18-year-old asthmatic needing intubation. He forgot his rescue medication at his grandmother’s rose garden.

  • The obese 10-year-old, crying after a closed fracture of his arm during a soccer championship. His six saves don’t matter compared to his excruciating pain.

  • The unconscious 22-year-old car crash victim with low blood pressure. Her three other companions are being airlifted and will arrive in a few minutes.

  • The 19-year-old known epileptic who continues to seize despite receiving diazepam and phenobarbital.

Cases like these often resemble those across many emergency departments around the country.


Emergency medicine doctors frequently use ketamine regularly to treat various conditions. The drug’s applications in the emergency department include:

  • Procedural sedation (Dilip et al., 2021)

  • Rapid sequence intubation (Ishimaru et al., 2019)

  • Acute pain control in place of morphine, fentanyl, and other potentially addicting opioid analgesics (Karlow et al., 2018)

  • Treating psychiatric crises (ACEP, 2017; Riddell et al., 2017; Barbic et al., 2021; Domany et al., 2020)

And many others. If emergency medicine doctors like you can administer ketamine in urgent, high-pressure situations, you are certainly prepared to administer it in a more relaxed environment for less acute clinical situations.


Emergency physicians have a keen eye for spotting patients needing this drug and the expertise to give it to them safely. So you should be confident about handling outpatient ketamine administration.


What Challenges Will Emergency Physicians Face When Opening a Ketamine Clinic?


The biggest issues that an emergency medicine-trained doctor may encounter when opening a ketamine clinic involve the following:


Funding


The number of physicians in private practice has diminished in the last few years, and COVID-19 aggravated the problem. The cause is multifactorial but overhead costs related to physician salaries have been implicated as a huge contributor to the reduced demand for ER physicians. The government and private funding agencies are willing to help doctors start and run their own practices (Provenzano et al., 2020).


Payment Collection


Ketamine infusion treatment for mental health is not covered by insurance, which can be really daunting for patients. A typical refractory depression therapeutic course has six sessions, with each session typically costing the patient $350-550.


Psychiatrists giving ketamine for treatment-resistant depression may be able to bill insurers for some aspects of the patient’s treatment, however, this should be implemented carefully and with the consultation of billing and legal. This can potentially let them reduce the patients’ out-of-pocket costs (Blum & Grey, 2021).


While you can’t bill insurance for therapy and other services as psychiatrists do, you have other ways to make ketamine treatment more affordable for patients with mental health issues. Partnering up with a psychiatrist is one. Doing so enhances your ketamine clinic’s diagnostic capability while potentially lowering therapeutic costs.


As for the other options, we discuss them in our article on ketamine and mental health insurance coverage.


Administrative Challenges


MBA-holding physicians are confident about their administrative and business skills (Delaney et al., 2014). Ketamine infusion clinics need such business-savvy individuals as badly as they do competent ketamine providers.


If you did not go through an MD/MBA program, you might want to pursue an MBA separately if you’re up for it. However, oftentimes it is more cost-effective to simply spend your time learning from a business mentor or from experience in administrative roles (Shah & Allen, 2018).


These challenges may seem overwhelming at first. But as in all other endeavors in life, a little perseverance goes a long way.


What Will Emergency Physicians Gain by Owning a Ketamine Infusion Clinic?


Here comes the best part of running your own ketamine clinic—what’s in it for you?


Full Control


Owning a practice lets you take charge of all aspects of patient management and business decision-making. You don’t have to be at the mercy of hospital administrators or insurance providers to do what is right for your patients (Delaney et al., 2014).


A Steady Income Stream


The impending shortage of emergency department positions can cause financial instability (Marco et al., 2021). If you’re good with people and are willing to acquire the necessary business skills, you can thrive by running your own ketamine clinic.


Less Saturated Business


Ketamine infusion therapy is a relatively new treatment for psychiatric disorders, chronic pain, and many other conditions. Running a dedicated ketamine clinic is likewise a newer form of business.


The number of ketamine centers throughout the US was estimated to be 60-100 (Nemeroff, 2018). However, in 2021 the quantity of practices offering ketamine therapy is probably closer to 5 times that number. Compared to many other types of niche medical practices, there is far less competition which means better odds of success for you.


Opportunity to Address a Medical Service Shortage


Psychiatrists estimate that around 2.8 million Americans have treatment-resistant depression (Zhdanava et al., 2021). When you add other ketamine patients to this number, such as cancer patients with chronic pain (Bredlau et al., 2013), you’ll realize that there’s a shortage of ketamine clinics in the country. By opening your own, you can fill this void and give quick relief to a lot of suffering patients.


Collaboration with Other Specialists


Working outpatient with other physicians gives you plenty of chances to advance your medical career. Your interactions can help you hone your clinical skills. Additionally, networking with other doctors can open more business opportunities (Wilkinson et al., 2017).

Running a ketamine clinic seems to be a massive task at first. But wasn’t that the same thought you had the moment you entered medical school? Yet you hurdled the difficulties, and before you knew it, you had treated multitudes in the emergency department.


With a little effort and ingenuity, you can add this milestone to your accomplishments.


The Ketamine Center is the Emergency Medicine Physician’s New Destination


If there are two words that can describe an emergency physician other than “rapid-moving,” it would be “resilient” and “resourceful.” These are traits that one needs to open a grow a business like a ketamine therapy clinic.


Skillswise, there’s no doubt that emergency medicine specialists are highly capable ketamine physicians. Adding business and administrative proficiency to your list of talents makes you fully equipped to start and run your own ketamine therapy center.


And when you see yourself conquering this field, you just might realize that you made the right moves to add an extra stream of income and future-proof your medical career.

References


American College of Emergency Physicians (2017). Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine, 69(4), 480-498. https://doi.org/10.1016/j.annemergmed.2017.01.036


Barbic, D., Andolfatto, G., Grunau, B., Scheuermeyer, F. X., Macewan, B., Qian, H., Wong, H., Barbic, S. P. & Honer, W. G. (2021). Rapid Agitation Control with Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial. Annals of Emergency Medicine, 1-8. https://doi.org/10.1016/j.annemergmed.2021.05.023


Beaudoin, F. L., Lin, C., Guan, W. & Merchant, R. C. (2014). Low-Dose Ketamine Improves Pain Relief in Patients Receiving Intravenous Opioids for Acute Pain in the Emergency Department: Results of a Randomized, Double-Blind, Clinical Trial. Academic Emergency Medicine, 21(11), 1194-1202. https://doi.org/10.1111/acem.12510


Bhatt, M., Johnson, D. W., Chan, J., Taljaard, M., Barrowman, N., Farion, K. J., Ali, S., Beno, S., Dixon, A., McTimoney, M., Dubrovsky, A. S., Sourial, N. & Roback, M. G. (2017). Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatrics, 171(10), 957-964. https://doi.org/10.1001/jamapediatrics.2017.2135


Blum, B. & Grey, J. (2021). Administration of Ketamine for Depression Should Be Limited to Psychiatrists. Current Psychiatry, 20(9), e1-e2. https://doi.org/10.12788/cp.0175


Bredlau, A. L., Thakur, R., Korones, D. N. & Dworkin, R. H. (2013). Ketamine for Pain in Adults and Children with Cancer: A Systematic Review and Synthesis of the Literature. Pain Medicine, 14(10), 1505-1517. https://doi.org/10.1111/pme.12182


Delaney, A. J., McCandless, B. & Kramer, J. B. (2014). Doctors Extending Their Education: Why an MBA? Is It a Degree of Success? Missouri Medicine, 111(3), 170-172.


Dilip, T. S., Chandy, G. M., Hazra, D., Selvan, J. & Ganesan, P. (2021). The Adverse Effects of Ketamine on Procedural Sedation and Analgesia (PSA) in the Emergency Department. Journal of Family Medicine and Primary Care, 10(6), 2279-2283. https://doi.org/10.4103/jfmpc.jfmpc_2140_20


Domany, Y., Shelton, R. C. & McCullumsmith, C. B. (2020). Ketamine for Acute Suicidal Ideation. An Emergency Department Intervention: A Randomized, Double-Blind, Placebo-Controlled, Proof-of-Concept Trial. Depression and Anxiety, 37(3), 224-233. https://doi.org/10.1002/da.22975


Fang, Y. & Wang, X. (2015). Ketamine for the Treatment of Refractory Status Epilepticus. Seizure, 30, 14-20. https://doi.org/10.1016/j.seizure.2015.05.010


Holloway, V. J., Hussain, H. M., Saetta, J. P. & Gautam, V. (2000). Accident and Emergency Department Led Implementation of Ketamine Sedation in Paediatric Practice and Parental Response. Journal of Accident and Emergency Medicine, 17(1), 25-28. https://doi.org/10.1136/emj.17.1.25


Ishimaru, T., Goto, T., Takahashi, J., Okamoto, H., Hagiwara, Y., Watase, H., Hasegawa, K. & Japanese Emergency Medicine Network Investigators (2020). Association of Ketamine Use with Lower Risks of Post-Intubation Hypotension in Hemodynamically-Unstable Patients in the Emergency Department. Nature Scientific Reports, 10(1), 1-8. https://doi.org/10.1038/s41598-020-58489-3


Kannikeswaran, N., Lieh-Lai, M., Malian, M., Wang, B., Farooqi, A. & Roback, M. G. (2016). Optimal Dosing of Intravenous Ketamine for Procedural Sedation in Children in the ED—A Randomized Controlled Trial. The American Journal of Emergency Medicine, 34(8), 1347-1353. https://doi.org/10.1016/j.ajem.2016.03.064


Karlow, N., Schlaepfer, C. H., Stoll, C. R. T., Doering, M., Carpenter, C. R., Colditz, G. A., Motov, S., Miller, J. & Schwartz, E. S. (2018). A Systematic Review and Meta-Analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department. Academic Emergency Medicine, 25(10), 1086-1097. https://doi.org/10.1111/acem.13502


Marco, C. A., Courtney, D. M., Ling, L. J., Salzburg, E., Reisdorff, E. J., Gallahue, F. E., Suter, R. E., Muelleman, R., Chappell, B., Evans, D. D., Vafaie, N. & Richwine, C. (2021). The Emergency Medicine Physician Workforce: Projections for 2030. Annals of Emergency Medicine, 1-12. https://doi.org/10.1016/j.annemergmed.2021.05.029


Motov, S., Drapkin, J., Likourezos, A., Doros, J., Monfort, R. & Marshall, J. (2018). Subdissociative Dose Ketamine Administration for Managing Pain in the Emergency Department. World Journal of Emergency Medicine, 9(4), 249-255. https://dx.doi.org/10.5847%2Fwjem.j.1920-8642.2018.04.002


Nemeroff, C. B. (2018). Ketamine: Quo Vadis? The American Journal of Psychiatry, 175(4), 297-299. https://doi.org/10.1176/appi.ajp.2018.18010014


Provenzano, D. A., Sitzman, B. T., Florentino, S. A. & Buterbaugh, G. A. (2020). Clinical and Economic Strategies in Outpatient Medical Care During the COVID-19 Pandemic. Regional Anesthesia and Pain Medicine, 45(8), 579-585. http://dx.doi.org/10.1136/rapm-2020-101640


Riddell, J., Tran, A., Bengiamin, R., Hendey, G. W. & Armenian, P. (2017). Ketamine as a First-Line Treatment for Severely Agitated Emergency Department Patients. American Journal of Emergency Medicine, 35(7), 1000-1004. https://doi.org/10.1016/j.ajem.2017.02.026


Shah, E. D. & Allen, J. I. (2018). How to Become a Physician Executive: From Fellowship to Leadership. Gastroenterology, 154(4), 784-787. https://doi.org/10.1053/j.gastro.2018.02.009


Shimonovich, S., Gigi, R., Shapira, A., Sarig-Meth, T., Nadav, D., Rozenek, M., West, D. & Halpern, P. (2016). Intranasal Ketamine for Acute Traumatic Pain in the Emergency Department: A Prospective, Randomized Clinical Trial of Efficacy and Safety. BMC Emergency Medicine, 16(1), 1-9. https://doi.org/10.1186/s12873-016-0107-0


Shrestha, R., Pant, S., Shrestha, A., Batajoo, K. H., Thapa, R. & Vaidya, S. (2016). Intranasal Ketamine for the Treatment of Patients with Acute Pain in the Emergency Department. World Journal of Emergency Medicine, 7(1), 19-24. https://dx.doi.org/10.5847%2Fwjem.j.1920-8642.2016.01.003


Souza-Marques, B., Santos-Lima, C., Araujo-de-Freitas, L., Vieira, F., Jesus-Nunes, A. P., Quarantini, L. C. & Sampaio, A. (2021). Neurocognitive Effects of Ketamine and Esketamine for Treatment-Resistant Major Depressive Disorder: A Systematic Review. Harvard Review of Psychiatry, 29(5), 340-350. https://doi.org/10.1097/hrp.0000000000000312


Tran, K. P., Nguyen, Q., Truong, X. N., Le, V., Le, V. P., Mai, N., Husum, H. & Losvik, O. K. (2014). A Comparison of Ketamine and Morphine Analgesia in Prehospital Trauma Care: A Cluster Randomized Clinical Trial in Rural Quang Tri Province, Vietnam. Prehospital Emergency Care, 18(2), 257-264. https://doi.org/10.3109/10903127.2013.851307


Wilkinson, S. T., Toprak, M., Turner, M., Levine, S., Katz, R. & Sanacora, G. (2017). A Survey of the Clinical, Off-Label Use of Ketamine as a Treatment for Psychiatric Disorders. The American Journal of Psychiatry, 174(7), 695-696. https://doi.org/10.1176/appi.ajp.2017.17020239


Zarate, C. A. J., Singh, J. B., Carlson, P. J., Brutsche, N. E., Ameli, R., Luckenbaugh, D. A., Charney, D. S. & Manji, H. K. (2006). A Randomized Trial of an N-Methyl-D-Aspartate Antagonist in Treatment-Resistant Major Depression. Archives of General Psychiatry, 63(8), 856-864. https://doi.org/10.1001/archpsyc.63.8.856


Zhdanava, M., Pilon, D., Ghelerter, I., Chow, W., Joshi, K., Lefebvre, P. & Sheehan, J. J. (2021). The Prevalence and National Burden of Treatment-Resistant Depression and Major Depressive Disorder in the United States. The Journal of Clinical Psychiatry, 82(2), e1-e7. https://doi.org/10.4088/jcp.20m13699