Dr. Zach Fisk runs a pain medicine practice. That is how he would describe it, and that framing matters. Acute Pain Therapies in Bellevue, Washington offers a genuinely broad range of interventions including stellate ganglion blocks, regenerative medicine, peripheral nerve stimulation, spinal cord stimulators, PRP, and radiofrequency ablation. Ketamine sits within that model as one of many tools, not the headline, but arguably the one that changes lives most dramatically when it is the right fit for the right patient. This conversation gets into how that practice was built, what drives the clinical decisions behind it, and what it actually takes to sustain something like this over nearly a decade. Dr. Fisk is a board-certified anesthesiologist with fellowship training in acute pain management and an MBA from Tufts. He opened Acute and Chronic Pain Therapies in Bellevue, Washington in 2016 after leaving a stable position at the VA, where the chief of anesthesia told him his idea for an outpatient perioperative pain service was dead in the water. Eight years later, he is still going. This conversation is wide-ranging and genuinely honest. Dr. Fisk talks about his dosing philosophy and why he does not find body weight to be the most useful guide, his experience billing insurance for ketamine and why he eventually went fully cash pay, the role of outpatient sublingual ketamine in his practice, and how he thinks about patient selection after nearly a decade of doing this work. He also shares what he would tell an anesthesiologist or pain physician who is considering opening their own clinic, and it is not the answer most people expect. What You'll Gain: • How Dr. Fisk built one of the most comprehensive multimodal pain and ketamine practices in the Pacific Northwest, and why he believes ketamine works best as part of a broader clinical model rather than a standalone offering • His honest account of the early days, including seeing two patients in his first month, the VA chief who called his idea dead in the water, and what kept him going through the uncertain early period • A detailed look at his dosing philosophy for ketamine infusions, including why he does not rely primarily on body weight, how he structures dose titration over one hour, and how he tailors protocols to individual patient profiles • The insurance journey that started with unexpected coverage, moved through clawbacks and audits, and ultimately led him to go fully cash pay, including his candid take on why insurance covers Spravato but not IV ketamine • How he thinks about outpatient sublingual ketamine prescribing, when he uses it, when he does not, and why he draws a boundary around prescribing it purely for psychiatric indications given his anesthesiology background • His straightforward advice for anesthesiologists and pain physicians considering opening their own clinic, including why he says this path is not for most people and what you genuinely need to be prepared for Episode 67 show notes: 00:00:00 Teaser: Risk, Stability, and Building Something of Your Own 00:00:17 Welcome and Meet Dr. Zach Fisk 00:01:43 Dr. Fisk’s Path: Tufts, Anesthesia, and Acute Pain Fellowship 00:02:35 The Idea for an Outpatient Perioperative Pain Clinic 00:03:56 Why Ketamine Became a Primary Service, Not a Background One 00:06:19 The MD/MBA Path and How Business Training Shaped the Practice 00:09:18 From Fellowship to the VA: Building an Acute Pain Service 00:10:21 Leaving a Stable Job When You Want to Build Something 00:11:31 “We’ve Never Been Trained in Business, So I Just Went for It” 00:13:21 Year One Reality: Two Patients in the First Month 00:14:00 Early Hiring Mistakes and Why a Startup Consultant Made the Difference 00:15:32 What Medical Training Never Teaches: HR, Finance, and Practical Skills 00:20:00 The VA Chief Who Called It “Dead in the Water” 00:22:08 The 80-Year-Old Test: Taking Risks While You Still Can 00:26:00 Inpatient vs. Outpatient Ketamine: Dosing, Duration, and Monitoring 00:31:34 One-Hour Infusions and a Two-Titration Protocol 00:33:05 Why Body Weight Is Not the Best Guide to Dosing 00:36:50 Building a Multimodal Practice: Services Beyond Ketamine and SGB 00:41:47 Patient Stories: When Ketamine Changes and Saves Lives 00:43:10 Red Flags, Patient Selection, and Honest Conversations About Success Rates 00:44:40 Outpatient Sublingual Ketamine and the Lucinda Grande Protocol 00:47:52 The Insurance Journey: From Clawbacks to Cash Pay 00:51:40 The Spravato vs. IV Ketamine Insurance Mystery 00:55:03 Advice for Anesthesiologists Considering Private Practice 00:57:31 Rapid-Fire Questions Begin 01:02:42 Where to Find Dr. Fisk and a Tip on Naming Your Business 01:04:33 Episode Ending Thanks for listening Connect with Dr. Fisk at: Acute Pain Therapies Website https://acutepaintherapies.com/ Instagram https://www.instagram.com/acutepaintherapies/ 📝 Complete show notes with resources and links, please visit https://www.ketaminestartup.com/podcast/episode-067 Follow us on Linkedin Ketamine StartUp Website YouTube 🚀Want to fast track launching your ketamine clinic? 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