Running the Medical Side of a KAP Clinic: Lessons Learned

Dr. Meidad Goldman 7:51

So we try to, obviously, we get all the physiological data that we need, oxygen saturation, heart rate, any type of movement is being transmitted directly to our phones from the ring that the client will have and but in general, we are in touch with the therapist, and we know each client, and it’s really very between client some client actually Appreciate if the clinician is kind of in and out a little bit more, because that helped them to feel supported, that helped them with their kind of teamwork, that we’re all holding the container that is holding the client, some client, this interaction, this in and out, may interrupt the psychotherapy process, and so we’re in touch with the therapist, as well as monitoring the drip and the patient at the same time. Obviously, if the therapist can send us a quick note saying, Hey, we’re talking about a really sensitive topic, kind of stay out over the next two minutes, we will try to minimize our interruption, obviously, as long as the patient is safe, so we can monitor them even when we’re outside the door, and can see exactly what’s the physiological parameter, the vital sign for the patient. And we go in, in and out and checking the drip and adjusting as needed if the drip needs to go faster or slower. But all of those consideration are based on the psychotherapeuticals that the client and the therapist have together, and they’re working together to really customize that drip, not only to each patient individually, but also to the content that come up, to the psychotherapeutic role and to the overall work that the client is working with your therapist, I

Dr. Signi Goldman 9:51

love that you said that you individualize it, because that’s definitely our ethos, this idea that some clients are comfortable with more interruption than some prefer less. Yes, and you’ve also already begun speaking about the individualizing the drip rate. So can you talk a little bit about what you mean by that, and what that actually looks like in the clinic on a day to day basis? Yeah,

Dr. Meidad Goldman 10:11

if there is an ideal zone of altered level of consciousness in which we want the patient to be and we can actually customize and individualize the drip rate to get the client where their ideal altered level of consciousness would be with respect to their psychotherapeutic goal, if the client needs to be a little bit deeper into deeper meaning, a little bit more altered with respect to the psychedelic outer level of consciousness zone, we can it’s not just a dose that needs to go up or down. It’s actually the drip rate that can play in because ketamine has a short half life, we can really adjust the rate. And if we need to go higher on the drip rate to get declined a little bit more sedated or more altered with respect to the psychedelic component of the medicine. And if they need, if we need to back up a little bit and the client needs to get a little bit less medicine, we can slow the drip and achieve our goals

Dr. Signi Goldman 11:17

in that manner. And so you’re describing that adjusting the drip rate is not the same as adding more medicine to their total dose. It’s really just the how rapidly it’s going into their bloodstream. So they perceive it as an increase, but it’s more controllable. Is that correct? 

Dr. Meidad Goldman 11:33

Yes, and that is correct. And so if client we can achieve in if you look at a spectrum of the of the psychedelic experience, from out of body experience to, you know, out of body experience, near death experience, ego dissolution experience, there’s, there’s an, obviously, it’s a spectrum, and we can really get the client to be in the right spot, and that’s based on immediate feedback from the therapist who sits with them that will allow us to really get the client to where they need to be to be able to handle the process and the content that comes up during The psychotherapy session. So in case

Dr. Signi Goldman 12:21

people are interested in this, what is the communication system that the therapists are using to let the medical staff know, hey, come in, or don’t come in, or maybe we need an adjustment. 

Dr. Meidad Goldman 12:33

So we let the client know that, obviously we’re all attached to this electronic leash.

Dr. Signi Goldman 12:38

So you’re holding up your phone, though, for those who are just listening, yeah, for those

Dr. Meidad Goldman 12:42

who are listening, the electronic glitch was referring to my cell phone, and they we let the client know that the therapist will communicate with us via text message, and so we are in communication with our therapists that are sitting with our client. And if there’s obviously a topic that is sensitive that the client or the therapist feel that me going into the room might interrupt the flow of the therapy, and as long as there is no need, immediate need, meaning vital sign or other needs that need to be addressed for the safety of the client, that we can hold back and we can communicate via the text when we’re in the room. We have our own kind of specific sign language that we can you know, simple sign language client is doing. Well, go up on the drip. Go down on the drip. We have our own lingo, one to four, one to three, talking about the drip rate of how many drops per minute are being infused to the client. So you’re using hand signals, and adjust all of those without any interruption to the client by using hand signals, by using hand signals. So we’re not talking there’s no talking shop while the client is sitting in the recliner in an ultra level of consciousness. And here we are talking about them and about the process, because that will be interrupting and distracting to the client.

Dr. Signi Goldman 14:18

And if the client or therapist does want you to come in. How far away are you? How long does that take if they shoot you a text or

Dr. Meidad Goldman 14:26

all of our, all of our five treatment room are all on the same floor, and so it’s, it’s just, I’m few bitter down the hall, you’re talking about, you know, five to 10 second and we’re in the room.

Dr. Signi Goldman 14:41

I think that gives a good sort of visual of the flow and and what’s happening in the room. How do you choose doses for people? And let’s start with initially, say a client comes in for the psycho for the ketamine assisted psychotherapy treatment program, and they have been assigned to a therapist, and you. Their first meeting with you. How do you determine the initial dose?

Dr. Meidad Goldman 15:04

That’s a great question, and the first I will start by saying less is more. I’ve been saying it all along, and I’m approaching our eight year since we open our clinic, coming up and sitting with client over the past seven years, I would say less is more. There is a finite amount of receptor that needs to be saturated with ketamine to achieve an outward level of consciousness that will allow the client to really have this kind of out of body, mild psychedelic, psycholytic, which is psychedelic light, the way I call it. But the psycholytic, psychedelic, altered level of consciousness, still out of body, but not all the way to near death or ego dissolution. The typical dose that everyone is talking the point five milligram per kilogram really comes from the depression protocol and the studies that were done on that. And I would say it’s a good starting dose for a client. I would say that the majority of our client will end up anywhere between point six to point nine milligram per kilogram with less is more. And I will repeat that, and I always give client the example. You know, if you drink a glass or two of wine, you can feel chill, but if you drink the whole bottle, is not going to make you any better. And that’s the same for ketamine or any other psychedelic. And even the maps research showed us that the kind of intermediate zone was the most effective. We start at around point five milligram per kilogram. We take into account has the client has any psychedelic experience that is important. Obviously, people that are had psychedelic experience that are a little bit more accustomed to altered level of consciousness compared to someone who is completely psychedelic, naive, so to speak, that will make a difference. We obviously those people not based on their actual body weight, but we take into account their ideal body weight. You can have a client that is 300 pound, or someone who is 150 pound, but we’re treating the nuggets, and pretty much they’re all about the same size. So consider,

Dr. Signi Goldman 17:31

if you’re referring to their brain,

Dr. Meidad Goldman 17:33

brain, considering the fact that we’re treating the brain, then ideal body weight, rather than actual body weight, needs to be taken into consideration. And obviously, each person will metabolize the medicine and will be affected by the medicine differently. Some people are lightweight, so to speak, and some people needs to hold six pack. We will estimate and start somewhere around the point five, milligram per kilogram, with a caveat that our first treatment in the experience that the client is having will help us to determine whether or not going up or down

Dr. Signi Goldman 18:14

is really necessary. First one is like a dose finding session, usually around the point five, and then yes on how they do. We’re entering

Dr. Meidad Goldman 18:24

an era what is being coined experiential medicine. This is the first time in medicine where we’re entering where we have a drug that not only have a pharmaceutical effect. Most drugs until now, you take a pill and you hope for a pharmaceutical effect. Even with psychoactive medicine like SSRI, benzodiazepine, opioid, you take a pill and you hope for an effect, but the pill itself will not give you any experience. And with ketamine, when you administrate the ketamine, you have an experience. That’s the psychedelic element of the medicine plus potential pharmaceutical but the experience is really what’s going to help us to kind of learn where the patient needs to be with the point that we’re taking the pharmacological effect that we want to Harvest as well. And so it’s a combination of what evidence based medicine will tell us the point five milligram per kilogram, but really titrate to the experiential element and not just the pharmacological element. And on top, we have the psychotherapy. And so we get feedback from the therapist who is sitting there, we check in on the experience that the client have, and we’re looking at the pharmacological range where they need to be based on their ideal body weight and other factor that we take into effect, other medication that may interact with ketamine and other physiological state that. That is important to take into account.

Dr. Signi Goldman 20:02

So I know you’ve been doing this for almost eight years now, which, by the standards of KAP clinics, is a long time. I imagine there are things that you started out doing that you learned by experience were not the best, or that you learned some things that to do better over time. So if those who are listening, who are starting from the beginning, maybe can learn from your experience, what are some of the things that you started changing over the span of those years as you were practicing on the ground and seeing what the work was like,

Dr. Meidad Goldman 20:35

I think the first thing is, you know, as far as the dose, less is more, we all have the urge to help client, and if the client didn’t necessarily have the best experience or didn’t respond, our initial instinct is to, oh, let’s go up on the dose. And I until today, seven years later, I have to fight that urge and to remember that less is more, because it has proven through the past seven years, two, we started providing a specific music track that incorporate by neural bits that can put the client in a certain frequency their brain will be in a certain frequency. We typically aim at the Alpha range, and I change it because initially you can tell the client, hey, why don’t you bring music that you like? But I find out that music almost like smell that you can smell the soup and it will take you to your grandmother house serving music. When the client brings that will have an association that may not be the best for the therapeutic container that we’re working so providing them the music truck, have control. Essentially. What I’m saying is that have control on the setting. You cannot control the set, as in mindset, but the setting is important. The visual that the clinic is set and provided, the music that we’re providing to the client, the blankets that we’re providing them, the IMS that we provide, even journals that allow our all those things are very much contributing and affecting the result of the therapy process that we’re working with our client.

Dr. Signi Goldman 22:25

Yeah, that’s interesting about the music. I’m going to ask you more about that in a little bit, because I think that’s just a really one of those topics in psychedelics that has so many opinions. And I think your experience there is really interesting and has been born out over time by the rest of the staff’s observations, including the therapist there. But before we get into music, speaking of controlling the setting, I imagine there’s been times when you’ve had providers in or out of the room that the client doesn’t know as well. And I’m just curious what you notice or what difference that makes when the client knows the treatment team better versus when there’s someone new or different there?

Dr. Meidad Goldman 23:08

I think it makes a big difference. I think it makes the big difference because the client, even though we talked from the beginning that every ketamine session is going to be different, almost like lucid dream, and you never have two of the same dream. You never have two of the same ketamine experience, so to speak. It’s going to be different. But having a provider and a familiar face that they’re familiar and used to, someone that they can trust, someone that they have interacted in the past. We build rapport. We know their entire support system. I know who brought them, who’s going to pick them up. Family. We can talk and almost as a physician, I think it’s parallel to any other client that I see, either in the emergency room or in a house call or in the clinic. If you do build this rapport with the client, it makes a big difference and allowed the client to really be at ease from the minute they walk into our office.

Dr. Signi Goldman 24:15

So back a little with the subject of music. You’re using a sort of subtle, you said, alpha wave, binaural beat track that it sounds like most of the therapists have in the clinic have sort of become accustomed to and work with, or do some therapist or patients like to use their own music. And just what are your thoughts on that

Dr. Meidad Goldman 24:39

most of the therapists in our clinic will use our track that we have with the years. You know, we started our clinic in 2017 and initially there was a lot of experiment and experiment, experimentation. With the music, where the client brings their own music, or the client select with me, or the other clinician what type of music, and later, we kind of gravitate toward a specific track that is really in the background and it does not direct the client. I always consider the music is almost like flying carpet that just allowed the client to kind of float, and if they need to fall back on that carpet, on that music, to re anchor their thought process and then venture into a specific thought or feeling that it work, some therapists in our clinic do bring their own music, but again, this is music that they have kind of curated or selected specifically for that client. And so overall, I would say, have the clinician control the setting and bring the specific music, rather than the client bring in the wrong music, typically, it has some association that may not necessarily be the best. Obviously, there is exception to all of that. And as far as the music type, background music, we know words in our selection, and that really kind of is not pushing the client and directing the client to have a specific experience, but something a little bit more neutral that that will allow them to just kind of rest on the music and flow of it, versus being directed by the music,

Dr. Signi Goldman 26:46

especially because the therapists are really having a conversation over the music, and that conversation is a psychotherapy interaction. Yes, that makes sense that you don’t want the music or the tone, the emotion of the music to go run counter to what’s happening in the therapy session. So I think that makes a lot of sense, and I know that we have, we’ve all kind of gotten on board with that over time, as working better in our clinic over the past eight years. Yeah. So I know that you run a consulting business, and you have taught, trained and mentored a lot of physicians or medical providers that want to do the exact same thing you do run a KAP clinic, everything from how to find a site and how to set up your your legal entity and run the administrative aspect of the practice, how to obtain ketamine in the right Ways and how to dose it for the different routes, how to run things on the ground, how to schedule and so on. So I know that you’re a wealth of information and already do a lot of mentoring in this in case, I’ll also put that information along with this podcast so people can reach you for that. But I want to ask you a few more specifics that might help just the general audience who’s listening in, take some pointers for how they’re setting up their own clinics. So one is, I know your appointment times are two hours long, I’m curious kind of the flow of how that time increment was chosen, and what the flow of that looks like, as far as what happens when, when the IV drip starts and stops, and walk me through that two hours. 

Dr. Meidad Goldman 28:28

So our in our clinic, we we started nine in the morning, and we go, we’re in the clinic until five in the afternoon. But I will take the example. I mean, some patient will start at nine or 10 or 11, but let’s take the nine o’clock patient as an example, the appointment time of two hours. I think it’s important. And I know that most clinic are not necessarily that generous with your time, but I feel that, again, this is important because you want to allow the client an ample amount of time to not only benefit from the psychotherapy, psychotherapy with their therapist, but will have an adequate time to drop in And to exit with this many integration that the therapist and our clinician are doing. So the nine o’clock patient arrive to the clinic. They will take into their private room. The nurse will go in with them, with one of us, one of the clinician, typically, and check in with the patient. First of all, from a medical point of view, has there any change in medication? Has there any change to their physical state that we need to know, that may affect and then dropping into the psychological, emotional rim of entering this. I can call it a sacred space of their journey that they’re about to have. And the check in is around 15 minutes from nine to 915 where we will check their vital sign, make sure that the client is ready, physically, emotionally and mentally, to enter their journey and place an IV. And by 915 920 at the latest, the client is ready in a supine position on the recliner with the blanket in the eye mask for the drip to start. The drip itself will go for about 45 to 50 minutes. And so if we start at 920 for example, we will go until 10 past 10, in which the patient are still going to fill the medicine and altered. Even after the bag is empty and all the medicine is in, it will still feel the effect of the medicine for another about 15 minutes, maybe even 20, but around 15. So if we start at 920 the bag will run until 1010 the client will still feel the effect of the medicine until 1030 at that point, at 1030 until 11, the therapist can still have some time to do a mini integration and works on the things, the immediate things that needs to be addressed while the patient is kind of back into their normal level of consciousness. And by 940 or so, we will come in to the room after checking in with the therapist that it’s a good time for us to enter, to get the AV out, to assess the patient, physically, medically, that the patient is feeling okay, that their session went okay, both physically, emotionally, mentally and around 1050 or so the client will be ready to leave the room, so around almost two hours. And obviously we have, you know, those 10 minutes buffer if they need an additional time and need to talk to the therapist. We have a recover room in our clinic that if the client is not is being picked up, or they need some more additional time, they can go into the recovery room, which is the private room where we can provide them a little snack, something to drink, keep checking on them, obviously, while they’re over there, but That’s pretty much the time between nine and 1050, to 11, where the client is ready to depart and being picked up by either family member, loved one, or whatever means of transportation. And obviously, if they need extra time in the clinic, we have the space for that.

Dr. Signi Goldman 33:02

So I don’t want to spend a lot of time today on other medications, because I think people can approach you individually, and you’ve done other work public, publicly talking about this, but I know that your philosophy is not to provide other medications in the IV with the ketamine, just ketamine, but you do provide as needed medications for things like blood pressure or nausea, but I believe in the clinic, it’s pretty minimal because of the thorough medical screening that people have ahead of time. And I thoughts that you just want to put out as the most important things without you know necessarily going into all of your policies, but things that you just think people need to be aware of there.

Dr. Meidad Goldman 33:44

So we do have nausea medication, we can provide it both IV or sublingual dissolving tabs. So friend is most commonly used. I can tell anyone who experience nausea in other clinics, if you dose people correctly, the number of people who need any type of nausea medication, I can count on, on one hand, the past three years of client that needed nausea medication, and many time it’s not, it’s may not be even the medication. It could be the content and the emotional things that they’re dealing that contribute. But we do have medication. We have medication for blood pressure. If their blood pressure is high because of their emotional state or not control, we will be able to provide them. And obviously we have as a backup. And so far, knock on wood, we never needed to even use them. But we do have benzodiazepine available in the clinic, and all of the other medication that we need as a clinic for resuscitation. But again, knock on wood, in the past almost eight years, we have never used them.

Dr. Signi Goldman 34:58

I want to circle back to the. Thing that you said was your main learning opportunity, and also the is the same thing that I think you have said before, that you feel like a lot of other clinics make the mistake of which is the dosing, and you’ve also named that there’s a lot of kind of push from clients or other providers, or sometimes even from yourself, to go up, and you’ve learned to resist doing that. And I know we’ve discussed in the past, when we have patients coming in from other clinics that they often have a history of being dosed way too high to do effective KAP work,

Dr. Meidad Goldman 35:37

and the client will tell you, they will telling you, Oh, yeah. And they needed to give me medication. They need to give me, like Ativan or some other benzodiazepine, or they need to give me Zofran, because every time I’m getting nauseous, and when you ask them about the recall from their session, they can’t relieve and be sure exactly what happened. And so, yeah,

Dr. Signi Goldman 35:59

I mean, just to put it colloquially, they need to be able to talk to their therapist and have a conversation. And yeah,

Dr. Meidad Goldman 36:04

I like my patient to be what I call in the in the 30 to 40,000 feet view where they are up here, and having a direct view of their life, but able to interact and able to see things. But if you give too much, you push them to the stratosphere and beyond to to beyond the atmosphere, and then you essentially, it’s a return to your investment, diminish result. And I see that over and over again, where where reclined are being dosed too high, their therapy process is being affected.

Dr. Signi Goldman 36:44

So let’s just talk then briefly before we end about what we think might be the most useful take home point for some people looking to have your job and do what you’re doing, and that is on this subject, how do you and the therapists deal with situations which I know are common, where the client will say they think they need more medicine, or they don’t feel it enough. So

Dr. Meidad Goldman 37:11

first I would say that you know, everything that we learned in medical school or or in residency, really, none of those things is prepare us to the work that you’re doing in the ketamine clinic. I mean having client going through altered level of consciousness and a psychedelic trip, and talking about things that are not they’re not in a day to day rim, most, some people will call them in the Woo, things that is not something that that you have been prepared for. And so being open to that as a Western allopathic medicine, educated physician, and being open to other things that we may not be able to explain on the day to day, is very important to allow yourself and in terms of I deviated from your question, but the day to day is to just keep in mind each client individually and try to get them to where they need to be.

Dr. Signi Goldman 38:18

So if you are called into the room by a therapist or who says the client is asking for more medicine, or they they think they’re not. Nothing’s happening. Are there techniques that you or the therapist use to sort of work with that lower dose? Because I know that another option is going up on the dose, and also you have learned over time that it kind of works better not to do that most of the time. So I think there’s a lot

Dr. Meidad Goldman 38:50

first you don’t need to go up on the dose. We can just increase the drip rate and allow the client to drop in a little bit more if needed. But in addition to maybe increasing the drip rate, something is happening to the client. And often they either resisted because of whatever they have been working on or the things that they were coming into the treatment, they would not let go. They have to be in control. They’re not at ease, and they’re not relaxed. And so often, when you see the client saying, I don’t feel anything nothing is happening, is typically because they’re not ready to kind of drop in the session.

Dr. Signi Goldman 39:38

And by drop in you mean sort of relax, or let it take over

Dr. Meidad Goldman 39:42

relax and allowing the medicine to kind of guide them into the where they need to be. The other aspect is that what I see in ketamine is that the things that we suppress on a daily basis are kind of going to come up. During the ketamine session, all your things that you have suppressed in your subconscious or unconscious are going to come up, and many times, the client is having kind of a hard time with those thoughts and feeling, and they will try to resist them and try to block them. And that’s where, necessarily, the therapist and us is trying to work with the client to allowing them to drop in more and to see what is it that they do feel, and what is it that they do think and feel, both physically and mentally during that time,

Dr. Signi Goldman 40:41

and a lot of this is the techniques the therapists are using. Yes, coach the person to work with what’s already happening, and rather than assuming they need to be at a stronger dose,

Dr. Meidad Goldman 40:54

correct? And the answer is not necessarily going up on the dose, there’s other technique that can help the client experience to be shaped without necessarily just increasing the dose but allowing them

Dr. Signi Goldman 41:09

so I’ll just put a plug here for LMI therapy training programs, we actually teach therapists these very skills. So I know you’re on the medical and prescriber side, but I just wanted to get you know, to hear you speak to what that looked like from your end, before we we close. How about just a more fun question, like, what is sort of the strangest part of your job? Like when people meet you and they say you do what? What are some things that surprise you, or they just find interesting or that you didn’t expect,

Dr. Meidad Goldman 41:42

working with client and allowing them to drop into a different phase of life. Well, they’re still a word. They’re in the clinic on the recliner talking to me, and yet they could meet a deceased loved one who is no longer with us, and have a meaningful interaction and conversation or meeting their young version or an older version of self, and how is that come apart and talking to client as they’re getting ready for their journey and as they emerge of their journey has really opened my eyes to the things that are not being taught in medical school, and really be open that anything and everything is possible, and really allow the client to drop in without any preconceived notion, without any judgment, without any type of criticism, but really allowing them to go wherever the psyche needs to take them. I think the psyche knows kind of where, they need to take someone, and it’s really beautiful to see that happening as you work with a client from start to finish.

Dr. Signi Goldman 43:11

So any last words of advice for medical providers who maybe where you were eight years ago, wanting to get into this work and sort of not sure what to where to start

Dr. Meidad Goldman 43:25

before we close. Well, first of all, first and foremost, they’re still all about the patient. So doing the right thing for the patient is the number one things that go in front of me, in front of my eyes every single day. It’s a real privilege and an honor to participate in someone’s journey, and then to really allow yourself to decide if you want to devote yourself to a ketamine clinic is to understand that administrating the medicine is only one small part, but holding the space and holding that container is the bigger Part of the job, and be ready for that. If, if this part of the job is not your cup of tea, then running a ketamine clinic may not necessarily be the best route for for you.

Dr. Signi Goldman 44:35

That’s a great answer, such as someone coming out of Emergency Medicine with a busy ER, you would know, right, very, very different energy.

Dr. Meidad Goldman 44:46

It’s a different energy. It’s a different energy. It’s still an honor, but it’s a different energy and a different vibe. Yes, medical knowledge is very important, but it’s beyond the medical and a. Think that that become evident over the last seven, almost eight years and have made me a better clinician.

Dr. Signi Goldman 45:10

Well, thank you so much for doing this. Today, we’ll add the information to this podcast and video form about how people can reach you for mentoring or career counseling, and you also do trainings where people travel and shadow you in the clinic, as well as a lot of that over zoom. So we’ll put that information, put it out available. You can also find that on Living Medicine’s website@livingmedicineinstitute.com, so thank you for coming. It was fun to interview you, and we’ll close and have you back on in the future.

Dr. Meidad Goldman 45:43

Thank you for having me.

Outro 45:46

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