Ketamine, Depression & the OODA Loop: How Ember Health Reorients the Patient Journey

Purpose can start as a conversation and grow into a clinic that saves lives. We sit down with Dr. Nico Grundmann and Tiffany Franke of Ember Health to explore how a marriage built on service turned into a patient‑centered model for IV ketamine that blends rigorous science, design thinking, and deep human care.

Nico breaks down the medical backbone: why ketamine’s decades of anesthetic safety matter, how weight‑based dosing and in‑room monitoring reduce risk, and what 30,000+ infusions taught the team about outcomes, side effects, and durability. Tiffany opens the black box of “set and setting,” showing how language, space, and therapeutic communication shape results—right down to crafting tea rituals and training clinicians to guide altered states with steadiness. Together, they explain why Ember won’t start without a third‑party diagnosis and a live handoff from a therapist or psychiatrist, and how therapy during the neuroplastic window turns rapid relief into lasting change.

We go inside powerful stories: a retiree who finally feels joy after decades of depression; a mother whose therapist said she couldn’t wait weeks for SSRIs and needed help now; adolescents stuck outside school and hope who regain traction with carefully coordinated care. We also tackle access head‑on. Out‑of‑pocket barriers are real, so Ember has been building the data case for coverage—partnering with perinatal and pediatric specialists, publishing real‑world results, and engaging insurers, the VA, Medicare, and employers to move this into mainstream mental health care.

If you’re curious about safety, set and setting, postpartum depression, adolescent treatment, or how insurance is changing, this conversation offers a clear view of what gold‑standard ketamine care looks like and why trust is the first medicine. If it resonates, share this episode with someone who needs options, subscribe for more purpose‑built insights, and leave a review to help others find the show.

John R. Boyd's Conceptual Spiral was originally titled No Way Out. In his own words: 

“There is no way out unless we can eliminate the features just cited. Since we don’t know how to do this, we must continue the whirl of reorientation…”

A promotional message for Ember Health.  Safe and effective IV ketamine care for individuals seeking relief from depression. Ember Health's evidence-based, partner-oriented, and patient-centered care model, boasting an 84% treatment success rate with 44% of patients reaching depression remission. It also mentions their extensive experience with over 40,000 infusions and treatment of more than 2,500 patients, including veterans, first responders, and individuals with anxiety and PTSD

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Transcript

Milestones And Guest Introductions

Mark McGrath 0:20

Punch, I'm excited today. We we're gonna hit some uh some milestones, if you will, uh No Way Out. You know, we're over 150 episodes. We uh we have a vast network across a lot of different industries. One of those has been taking care of veterans with PTSD and hitting around consciousness and psychedelics and others. And we're bringing a guest back for the first time, but this is our first ever conversation with a married couple on No Way Out. We're we're honored to have not only our first married couple, but our first sponsor, Ember Health, which we're proud to sponsor and we're proud to tell their story. Um, and really that's why we have them here today. Dr. Nico Grunman comes back and he brings his better half, Tiffany Frankie. How are you, Tiffany?

Tiffany Franke 1:06

I am so delighted to be here.

Origins Of Ember Health

Mark McGrath 1:08

Well, we're glad uh we're glad that you're here. Nico, we're glad that you're back, and we're glad that you brought a friend to uh to help tell the story. So, you know, let's let's just go right into it. You know, we last time we covered the the science of uh of treatment with ketamine and how it helps veterans uh physically. Tiffany, let's get your side of the story. Give us the uh give us the story here of how did Ember Health start and and color in the mission for us.

Tiffany Franke 1:33

Yeah, well, first, Mark and Punch, thanks for having us on. It's an honor to be your milestone first married couple. But this is our first, too. This is our first podcast together.

Mark McGrath 1:44

Um congratulations.

Tiffany Franke 1:45

Yeah. Milestone for Ember Marcus.

Mark McGrath 1:47

Hopefully the first, hopefully the first of many, and others will follow our lead.

Tiffany Franke 1:50

Exactly.

Mark McGrath 1:51

We'll see how today goes. All right, let's do it.

Tiffany Franke 1:54

So I think, you know, the founding of Ember really comes from the founding of our relationship, our partnership. Nico and I have been married for almost a decade, and we met two years before that. And on our very first date, we met and we talked in earnest about our shared commitment to leading a life of purpose, to our service orientation, which I can imagine resonates deeply with the two of you as well as with your listeners. I'm just kind of deeply ingrained in the two of us. And for us, we were really excited by the concept of systems level change. I was an organizational strategist by training and background. So for me, not industry agnostic, but just really interested in how to have a positive impact in the world, in the business world. And so we had a lot of flights of fancy in our in our relationship about what that might look like. Of course, Nico being dedicated to the healthcare arena. We talked a lot about different ways that our capabilities could potentially help from how to ensure access to healthcare services in rural America to mental health services. And of course, that was the foundation of Ember. But really, I think the founding of Ember comes first and foremost from our commitment to wanting to maximize the impact that we can have in the world and to help people realize their full potential. Because what we both realized we believed in early on was people at their best, right? If we can unlock people's full potential, we're pretty humbled by what our species can do at their best. So, how can we work together to make that happen? So those were some of the some of the very seedlings, but in terms of why Ember specifically, um, if you'd like me to expound there, happy to Well, it's interesting.

Dr. Grundmann 3:33

So can I can I jump in for a second? Because I want to uh uh highlight that date. We we were in our early 30s, we met online through Hinge, so we had So wait, so Tiffany didn't come into the ER and you treated her.

Mark McGrath 3:48

That's no, no.

Dr. Grundmann 3:49

I I in fact left an ER shift thinking I was gonna be late to that first date. I had texted her. So I was working at Kings County, the kind of trauma. And tell us where that is. So New York City, Brooklyn, um, one of the New York City public hospitals called Kings County Hospital. It's a trauma center. So I was actually working one of the trauma shifts there.

Mark McGrath 4:09

And Tiffany, where were you working? Were you at like a big box consultant or no?

Tiffany Franke 4:14

I had I had struck out uh as a tech founder. I had a startup that had what we call think tanks on demand that was bringing together curated groups of experts and digital platforms to try to solve really big and important problems with corporate leaders. So I was uh trying to make that work. And there was absolutely no way other than having some platform that would bring us together that we would have crossed paths. So very great.

Mark McGrath 4:39

And then just a refining question, because we know that Nico was raised as the uh the most interesting man in the world living uh living amongst tribes and other things. But where did where did you grow up and go to school?

Tiffany Franke 4:50

So I grew up in Ducksbury, Massachusetts, that's on the south shore of Massachusetts, south of Boston. I I have two older brothers, wonderful parents, a very supportive family. Parents, I think Nico and I were talking about this before the show, how we're influenced and shaped by and our values, shaped by, of course, our parents, first of all. I mean, they were leaders in their community from the arts, local arts, and culture to, you know, my soccer team, football team. My dad had started a company. I'm so inspired by their example. And then community service was always a big focus for me, wanting to engage in my community in Duxbury. I went to boarding school. I went to Deerfield Academy in Western Mass. And then um I went to Yale undergrad. And I actually took, I took a gap year in between Deerfield and Yale, which was really influential for me. I went to Peru. I was always very curious about other parts of the world, other cultures, and wanting to see how I could be a part of helping in different communities.

Dr. Grundmann 5:47

You're also skipping your six months on Glacier in Alaska.

Tiffany Franke 5:50

Well, there are all sorts of things. Outdoors, uh really.

Mark McGrath 5:53

You two are the Doseckies commercial. You're the Doseckies couple. The most interesting couple. All right. That's good.

The ER Date And Purpose

Dr. Grundmann 5:58

There was a reason that there's date went so well. Okay, let's hear it. Well, so to highlight, uh so I was on this trauma shift and we had agreed to meet that evening at a bar in Brooklyn. Um and as I was finishing my shift, we got a 911 notification of a gunshot wound in the neck that was coming in. And my replacement hadn't arrived the ER yet when I got that note. So it was a funny text message to Sand Tiffany, because we hadn't met yet, being like, hey, I might be late for this date. Somebody just got shot, and I need to stick around until we can stabilize them. Um and lo and behold, that person came in. They had a bullet wound kind of entering the neck and leaving the side of the neck, and kind of astoundingly had missed everything important in their and they were okay. And right when I thought I was going to start not being able to make the date, my replacement showed up. And I was able to kind of uh skedaddle out of there as they were able to make sure this person was okay, made it to the date on time, which was something I was very proud of for that first one. And then as Tiffany mentioned, in a bar in New York, two people who'd never met, we we literally spent hours talking about what a life of purpose meant to each other.

Mark McGrath 7:06

See, I would have talked about the gunshot wound, but that's that's awesome that you were able to get past that.

Tiffany Franke 7:11

Nico, Nico's so conscientious. He had texted, you know, so many people just ghost you, right? And he'd texted me earlier in the day. I'm confirming our date tonight. I'm looking forward to it, kind of a certain formality, and I thought that was adorable. And then, you know, he said he'd be late and he was like exactly on time, you know, which is the discipline of an ER doc, too.

Dr. Grundmann 7:30

Well, and and then we were engaged six months later. So it was very clearly gonna work once we started uh actually getting to know each other.

Mark McGrath 7:37

So you guys weren't messing around. That's good. So walk us through the minute where I don't know, all of a sudden one day Tiffany's like, or Nico's like, hey, let's start a ketamine therapy clinic. Like, how how do we get there?

Tiffany Franke 7:49

I can I can share that, sure. I was so after shortly after we'd met, I wound down the other startup and joined a boutique consulting firm in New York called Incandescent and an organizational strategy boutique. And I was working late one night at my firm and Nico gave a call from Shift. He was doing locum's work, which is like substitute doctoring, and he was in West Virginia. And on the call, he said, you know, Tiffany, first of all, it's really frustrating. No matter which medical facility I'm in, urban, rural, seeing a lot of people coming in with mental health issues underlying. And there's not much I can do here in this setting to help them in a meaningful way. And that's frustrating to me. And at the same time, as an ER doc, I use multiple times a shift this drug called ketamine, which is an anesthetic, which is safe, which is effective as an anesthesia. And I've been following literature as he does on how much lower doses this drug, when administered intravenously, has stunning results for addressing symptoms of depression. And in paper after paper, 75% of people are realizing relief of their depression quickly with limited to no side effects. And I remember on the call thinking, well, I know how big of an issue depression is. And I know that traditional medications, antidepressants don't have those efficacy rates. So if this really is that good, why don't we see it everywhere? What's, you know, what's the rub? What's the gap? But it was on that very phone call that I was Google searching and looking online at different clinics that existed, and there were a couple, but it was very spartan. And I'm I'm somebody who really takes time to deliberate and weigh options and maybe, you know, not as decisive always with decisions. But honestly, by the end of that call, said Nico, I think we should do this because it was very clear to see here is a huge problem, an unmet need and a white space. And what we realized was to do this right took a it would take a really thoughtful approach to entering the field. And we're happy to talk about that and how we thought about what is a model of care that we think is going to be best for patients. And we want that to be what we bring to market. So I invited Nico to come in to my office. I kind of treated him like a client almost.

Mark McGrath 10:11

And you guys are married at this point, right?

Tiffany Franke 10:13

Yeah, we were married at this point. This would have been a great origin story to our relations. So you know you brought him in, why would the rest is history? We were newly we were newly married. We didn't have children yet. We had a frameworks, good consulting models, asking questions. And we really came up with on that first whiteboard, three core commitments that are absolutely at the fundament of what we've built at Ember and how we've built it at Ember, which is commitment to evidence-based care, to patient-centered care, and to partner-oriented collaborative care. And we come back again and again every conversation with uh talent that we might be bringing onto the team, or when we're making a big decision as an organization, we come back to those core commitments that we'd whiteboarded together.

Mark McGrath 10:57

Yeah, I mean, that's amazing. And you stick to that. And that was how many years ago now? So how many what we're 2018?

Tiffany Franke 11:05

Yeah.

Dr. Grundmann 11:06

I will admit that was a a really cool and unusual thing to go through for me. Because I had strategy and system stuff on the kind of healthcare policy side of things, but Tiffany walked me through as if I was a client. Like she'd worked with health, large health systems previously. And we had some debates there that were debates. I mean, this wasn't like a we all perfectly see eye to eye. I had conversations about like, well, how do you um how do you find individuals who need care, how do you find new clients, and was talking about kind of directly going out and finding people, and she was very confident that this was something that, no, no, no, these are referrals. These are people's psychiatrists, people's therapists. You you don't advertise for this, you you build a trusted community of people who are already taking care of these individuals. And she handedly won that argument, and and that is very much the path that we've taken. And and it was very quick to realize that that made a lot more sense, that we weren't trying to replace people's providers, we were trying to augment their teams so that their patients could get this in a way to do that.

Discovering Ketamine’s Potential

Mark McGrath 12:02

Walk us, walk us more through, you know, Ponch, Ponch and I are constantly challenging and collaborating together on theories. And I'm just curious, walk us through your collaborative and creative process of, you know, two as soon as you said organizational consultant, I know I know Ponch went, ah, you know, because that's that's that's what we love to talk about and do in in um where we're Ponch has spent a lot of time. But walk us through your your sort of creative collaborative process of of really combining those two worlds. What what do you think was the key? Now, granted, I get we get it, you're married, you know, and but but from a from a creative uh partnership standpoint, give us a little color there.

Tiffany Franke 12:42

Sure. I would say one of the keys to our ability to work really well together for the last seven years, and we're partners in, you know, in every which way. We're we're co-parents, we're married couple, we're business partners. We have a lot of respect for each other's domains, smarts, and they're not all overlapping. So I think that's been very important. Our capabilities are complementary, they're not in competition. And so, for instance, Nico in the creative process, which is your question, would kind of give me the floor for all right, here's the framework that we're gonna operate under, here are the questions that I'm gonna lead, I'm gonna help facilitate the conversation and create the structure. Nico's the content expert. Niko has this incredible, almost encyclopedic mind and memory around data, facts, research. So when it came to devising what should a business look like, what should a patient experience look like, we really, I would say, fit in different parts of the puzzle and respect each other's different domains. And so that's a very big part of the creative process. I mean, some examples, this tea that we're drinking here, we offer tea following every single infusion for our patients. It's a core part of a symbol of hospitality, of warmth, of welcoming back, of grounding back in their bodies. We devised the four blends that we used ourselves. And that was my orientation towards individual experience and thinking through the perspective of a patient coming into our care. What do we want them to feel like? What are the tiny little details everywhere that are sending signals of safety, of comfort, of warmth? And Nico really respected that. We actually had a double blind taste test. He brought a very rigorous kind of scientific method process to aligning on four different blends. That's one small example, but they're infinite. And I would say the one area where our capabilities are very overlapping is in strategy and strategic thinking. I think thinking about where are we headed and how do we get there and what our unlocks at different moments.

Brian "Ponch" Rivera 14:46

Well, and there's a fantastic connection here between the concept of set and setting. So when we talk about affordances and creating psychological safety, what you just presented to us is just that is how do we create the environment that we can create psychological safety and all that? This is important. I think this is your strategy background, your understanding of consulting meets the complexity of the human body, right? So it's it's like the perfect Reese's peanut butter cup moments or snowmobile, right? It's it's this is the right blend. We go back into our archives of some of the guests that we've had on the show. Doctors will tell you, and again, I'm talking about Dr. Dan Lowe. He's actually an anesthesiologist up in Seattle, but he talked about how the medical community doesn't really apply their deep understanding of complex adaptive systems to how they deliver value and create that for patients. And I think this is what the moment you bring together here is hey, if we take this human-centered approach, you know, human human factors thinking and apply it to that setting and you start bringing this all together, you're going to create what you created, right? And this is, I'm loving the story because it's, I didn't know that your background, Tiffany, on what you did in the past and how it all comes together. But this is what we call like a snowmobile moment, right? Where we're taking things from different domains and bringing them together and you create this bigger impact. And I think, you know, with our background and and connections to the psychedelic assistant therapy world and PTSD TBI with the with the military, or at least the veteran community, this is happening. This, I'm sorry, this needs to happen more. And I think a lot of folks, I'm going to say there's a dark underbelly to this as well. There's a lot of folks that don't understand what you just said, uh, Tiffany, and how important that setting is for creating the conditions. One thing that I've learned about the, you know, mental health, TBI, PTSD, the different modalities for it is it's not necessarily the uh the ketamine that you deliver, it's the context it's delivered in.

unknown 16:36

Yeah.

Whiteboard Principles And Model

Dr. Grundmann 16:36

Well, there's another part that I think Tiffany was so good at, and and this was not my expertise. My expertise is to mention data, medical, I can do the doses, I can figure out the protocols. But from that first whiteboarding, Tiffany um put it in the context of a patient journey. What was it like from when they first heard the name Ember Health, and we were still arguing about the name and figuring out what it was going to be called, to they've been with us for years, and this is how they feel every time they come in and every time they and I can't emphasize enough that the level of detail and intentionality that this woman brings to everything that we do, and the ability to kind of put herself in the shoes of somebody who might be going through this and understand that, like, okay, this word, the single word in the single email that's like email number 52, matters. And let's make sure we got that word right.

Mark McGrath 17:23

Elaborate, Nico, like again, from so you're coming from different backgrounds. You know, your your your soulmate is is now your business partner. What what were the big, you know, and in with your background of as Tiffany was describing with data and this and that, what were the biggest awakenings that you had that she enlightened you to? And then Tiffany, I'm of course, I'm gonna ask you the same question. So go ahead, Nico, you start.

Dr. Grundmann 17:45

It was about that same kind of stuff. It was about the journey side of it. Like I could understand the this diagnosis, this treatment, I could help design the protocol and the data collection and like understanding how to leverage that for insurance in the future, et cetera. But I had underappreciated these are these are people receiving care, and that care is being delivered by people who work with us. And so everything interpersonal was structured by Tiffers. And she still runs our trainings on like managing difficult conversations and therapeutic communications and like how do we train our very talented staff on stuff they might not be used to in a healthcare setting, like how to talk to somebody in the altered state, how to support somebody when something becomes difficult during those sessions. And that's not normal healthcare stuff. It makes total sense when put into that context. But those are really where the merger of the skill sets started to really change how we practice. This, you get a little bit of a sense of it from behind me, but but Tiffany literally decorates the offices. She she designs them in a blueprint, she like makes whole floor plans of all of our spaces. She goes around and individually picks the furniture. She has sometimes painted some of our artwork as well as picked out our artwork, like every single detail that's been thought through by this woman to make it really shift how somebody experiences going through something that can be so life-changing.

Mark McGrath 19:01

Renaissance woman. So now, Tiffany, I'm gonna ask you the same question. What was the the biggest aha that, you know, from your background as an organizational consultant that uh that Nico brought to you that uh elaborated or, you know, I'm sorry, deformed your your thinking and and and made the uh approach more successful?

Tiffany Franke 19:20

Nico is, I mean, just deeply intelligent and has a degree of credibility about him because he's so knowledgeable. And I think that brings comfort to everybody who he talks to about something that otherwise feels a little unknown or scary or out there. I think the rigor of from very early days, for instance, committing to measurement-based care is something that I really appreciated and learned a lot from Nico in building in every element of how we're capturing information, which is very long-sighted because seven years in, it's now that we have a bulk of a data set, for instance, that's able to help shift the national conversation about what safety standards should look like. Because we've run 30,000 infusions and we see how many times certain medical complications came up, which is very small because this is a very safe space, but it's not 100% safe. So NEGO's foresight of what do we need to measure? Why does that matter? How might we use that? And how can that actually help shift the national conversation, not just at Ember, to make this field work for people is something that I learned a lot from. And then I think the entire field gains from.

Mark McGrath 20:37

And we uh it'll it'll edit out in the sound, but we can hear the national bird of Manhattan, the uh the siren in the background. So authentically, three of us are here in New York City. It hasn't come in my direction yet, but I'll probably I'll probably get a few minutes.

Dr. Grundmann 21:49

And Tiffany's first apartment was right near a hospital. And I got used to hearing ambulances all the time as an ER doc, but I will admit there are some times in New York City where it's hard to get away from that particular.

Mark McGrath 22:00

Oh, yeah. I I open up the window, quite honestly, even in the winter because the you know, the the the heat's so hot, but without the without the sounds, I can't sleep.

Brian "Ponch" Rivera 22:08

So I'm I'm a little curious about the information that you're collecting. You know, we've had guests on uh recently, uh a lot of guests on talking about the the power of narrative. Tiffany, I'm kind of curious with your background, uh have you considered capturing that narrative from the patients? And if so, how are you doing that? This one was a master. All right.

Designing Patient Experience

Tiffany Franke 22:27

Yeah, I mean, when we haven't talked necessarily about the barriers to access that we saw. And our mission is to help define gold standard of care for ivy ketamine for depression and then expand access to it. And so, of course, we're really thoughtful about well, what are the barriers to access? And one of the big barriers is stigma, misinformation, fear. And the antidote to that is awareness building and storytelling. We talk about the need for amplifying data statistics married with story and the individual of the individual person, and that we need to do that together, right? So you have an emblematic illustration of somebody's experience meets, well, how many people and what are the statistics around that? And they need to go hand in hand. And this is why, you know, programs like yours are just so important, they're platforms. Where people can help tell stories and myth bust. Um, I've am so one of the biggest hats that I wear still is my title as chief experience officer. So, of course, patient experience is number one, which means that you got to talk to your patients on a regular basis. You really have to listen. I've spoken to hundreds of our patients, and that's simply inviting them to a conversation. We have captured stories through those conversations that I've had, something called our Ember Chronicles, which are an anonymous set or anonymized set of stories, because we find that single quotes can be inspiring, like this saved my life, which is a true statement for many of our patients. But when what's really interesting is to get to the texture of their lives. What was their life like before coming to Ember? What was what were some of the challenges that people were experiencing? What was the experience of care like with us? What impact did that have tangibly on their lives? And Ember Chronicles is one way we've done that recently, and actually a really inspiring project I think you guys would be interested in. A former patient of ours is a documentary filmmaker. And he came to me and said, Tiffany, I'm just so inspired by the, first of all, the impact this has had on me, but I want to help tell the stories of Ember patients. We collaborated with him recently to tell the story, video stories of eight patients. And it was a very humbling moment to send an email to our patient population because I'm very respectful of people's privacy and of their discretion. And we said, if anybody wants to help us tell this story of impact, because that's what it takes to expand access, please let me know. And we got a couple dozen people who came forward and said, I want to be a part of this through just logistically speaking, who was able to work with us. We have eight patient stories that are videos that we're trying to disseminate and get out into the world because when you see yourself reflected in somebody else, a CEO, a founder who also has had lifelong suicidal ideation, a woman who really white-knuckled through depression through life and got to retirement and said, I'm gonna tackle this depression head-on, this hairy monster that's been following me. Then it just makes it all the more accessible and real and powerful. So we feel very passionately about helping people tell their stories in a way that's authentic, that's respectful.

Mark McGrath 25:39

Um, and that's with what you're allowed to share with us, you know, Nico shared, as you know, when you heard the podcast about the firefighter on the bridge. And of course, you know, we have a lot of vets, first responders, law enforcement that listen to our show, but we but we have a lot that aren't vets, law enforcement or military. So, you know, we have special needs parents and we have lawyers and we have corporate leaders, et cetera. Is there a story that's not military veteran or first responder, Tiffany, that really sticks out that shows how Ember, how that person engaging Ember went from one extreme on the dark side to the other extreme on the on the light side and and helped them in a in a way that would um send a signal out to others that they might want to do the same.

Stories, Stigma, And Narrative

Tiffany Franke 26:25

Yeah, I would point to actually the story that we just, the video story we just released, and she has shared her name and her story. Her name is Jean Allen, a remarkable woman, an elegant, talented woman. She's in her mid-sixties. She's somebody who she's been in the healthcare arena. She said she used to set up clinics. She worked with the homeless. She lived in Arizona for most of her adult life. And she's talked about how her depression was like this odorous, hairy monster that it takes the joy out of a lot of life. You're eating food, but you can't really taste the flavors. You're at a party, but you can't really enjoy the company and has a loving, devoted husband, an impressive career, and yet battling constantly suicidal ideation. And she is such a determined person. She said, When I retire, my job is going to be to figure this out. And so she had a checklist of options that she was running through. She tried at-home ketamine that did not work for her. She tried uh TMS that did not work for her. Next on her list was IV ketamine, and she went to a clinic in Arizona and she had her husband in the room, but there was no medical professional in the room monitoring, and she stopped breathing. And it was a life-threatening event. Good thing her husband was there and indicated that somebody came in. This is a very rare event, but a not zero event, which is why it's really important to have medical clinical monitoring. And she said, you know, I never wanted to go back to this clinic, but the thing is, it kind of helped. It kind of worked for me. Um so then she said, All right, I need to find Ivy ketamine, but in a model that I think is safe and really patient-centered. She and her husband, I have great respect. They moved to New York City, said, This is our new home. We've retired here. They just arrived and said, I think this is gonna be our place. And she ended up finding us and just felt so confident in having care coordination with her broader mental health team in a proper intake process, in very standardized, protocolized weight-based dosing, and having a medical physic uh clinician in the room with her the entire time and the psychological support that we provide. And she talked, I really love the metaphors that people use about when this works for them. And she said, when she was a kid, she wears glasses, and she didn't realize that you're supposed to be able to see individual blades of grass until she've had her first glasses, you know, because why would you? And she said psychologically, it felt like that with her treatment. Like I can think clearly, don't have I have space from this monster. And you know, she said in a in a in a very touching moment during the interview that she had a plan. She had a a plan to take her life if this it hadn't worked. And it and it did, it did work. And she's and she's said, I'm getting so much delight from life. You know, one might assume, right? You're the end of your life. So what does it matter? She said, I I believe I have 30 years left. You know, my family has longevity genes. I want to live those years. I'm doing art, I'm biking, and my husband's getting a lot more joy too. I was just so deeply inspired by by her because, you know, what she's been through through a whole life, and then still never giving up and knowing that there might be options out there for you and that there's hope, and then and then feeling brave enough to come forward and say, I have no other reason to tell my story than to help other people. So it's very amazing.

Mark McGrath 29:56

What yeah, well, it's also proof too, it's never too late to start all over again, um, as the Steppenwolf song reminds us. What about women with postpartum depression? That's another area I think that doesn't get a lot of attention or get enough attention. Um, and and you don't hear about this sort of treatment being available to them. Is that is that a demographic that you've been able to help with?

Dr. Grundmann 30:16

Yeah. We we actually had a couple weeks ago now, we had a whole mom brain event. Oh help coordinate and run.

Tiffany Franke 30:24

We also at the the ASKP conference, that's the American Society for Academy and Practitioners, presented a poster on our postpartum depression work, which we're really proud of because as far as we're aware, and we're in in the process of publishing it, it's the first of its kind of Ivy Academy for postpartum depression.

Mark McGrath 30:40

Yeah, tell us tell us all about that. That's uh let's also hear it.

Dr. Grundmann 30:44

Yeah, this Ponch to your point, this is the merger of data and stories. And this is exactly what we've been trying to do. Ketamine's used a ton in developing countries for people during C-sections, as kind of the reason to um help get them through a C-section without doing an epidural. Um, it's why it's on the WHO's list of 100 drugs every country's supposed to have on formulary. It's because it's just really common to use during birth um when you can't get an epidural. So we've had uh 60 something years of safety in ketamine for pregnancy and for childhood anesthesia. And so it makes total sense that if a mom is dealing with postpartum depression in these kind of first crucial weeks and months of a kid's life, fixing that depression quickly would make a big difference. You can bond with your kid. And a lot of the stuff that gets concerned around safety, well, we have literal decades of safety data at anesthetic doses, that this is okay for ketamine. And so that was the like nerdy data stuff that we were dealing with when we first started getting approached by moms who were dealing with depression and postpartum here number. And and we had long conversations about this about like, hey, data's here, uh, high-risk population are wrong. We want to be really confident that we're not causing harm. And so we had a series of conversations, including with a bunch of perinatal psychiatrists, like people whose professional field is managing depression during this time period. And we said, okay, no, we think there's enough here that we can inform consent, talk to patients, and say, here's what we know, here's what we think we know, here's what we don't know. If you understand all of this, we are willing to do this for you and see how it goes. And at this point, we've treated just 20 women in the postpartum period. We've treated breastfeeding moms, we've treated women who are a year plus out of their delivery, where it was a traumatic enough birth that they're still suffering from that. And it works the same as it works for everybody else with depression.

Mark McGrath 32:28

How about what's your Tiffany was remarking about a woman that was older? So what's the lowest age you treat? Because I'm thinking of teens with depression and teens with all sorts of anxiety issues and things that happen in, you know, particularly the early teen years, like in high school and things like that. Like what's what's the lowest you'll treat? And do you have any success stories there that we'd share?

Dr. Grundmann 32:49

Yeah, so similar to the postpartum mom group, which we now have a getting close to a multiple dozen patients treated and collecting data and then publishing that data. So that's what Tiffany was referencing. We have a partnership with Mass General Brigham with Harvard's Medical School, and they're taking the postpartum stuff that we've done and they're publishing that. So it's academic, it's peer-reviewed, it's not just an opinion, but here's what actually happened. The adolescents that we've treated is the same thing. We had a ton of conversations when we first started getting approached by parents of children who are really suffering. Children in this case is 14 plus. We we have good data for as young as 14 for ketamine for mental health. And we've treated getting close to two dozen adolescents in conjunction with their pediatric psychiatrists. These are often individual children who are adolescents who are suicidal, who are really just like have had a kitchen sink thrown at them. Often they've dropped out of school, they're unable to kind of function. And it works just as well as it works in adults. Um in that stuff I I presented some of this data two weeks ago. This is also stuff we're publishing where um from 14 to 18, if you've really gone through the gamut, this looks like it's just as effective as if you're older than 18 and and there doesn't seem to be much reason to wait um when people are really in need. So that's the data side. But but Tiff, I want you to talk about some of the stories there, because you you've done some interviewing, you've and actually some of these people have become quite public about their stories too. Can you add like Leah's story as the kind of the context narrative there on top of the data?

Tiffany Franke 34:12

For postpartum depression?

Dr. Grundmann 34:14

Sure.

Tiffany Franke 34:14

Yeah, and this is we did a a public panel, Nico was talking about a couple weeks ago, that we were really proud of, bringing together different practitioners in the maternal health space. Another very brave patient of ours who actually wrote an article for Oprah Daily talking about her experience with postpartum depression on uh it was after baby two, that she was not in a good way. She was not in a good place. And through the help of her support structure, her husband helped to get her a therapist who was very helpful. That therapist said, I think that you should try ketamine with Ember Health. And when she heard the word ketamine, it it was terrifying to her because she associated it with a recreational party drug. I think media does a lot of disservice without context and nuance and scares people. And she was at first hesitant, but also just seeking relief and willing to try anything. And this really helped bring her out of a dark place of stuckness and kind of get her on track. So she feels so thankful around that she wanted to go on the record and be an advocate for other people who might be in a similar situation. And we know statistically, about one in seven mothers is gonna experience postpartum depression. It's very common. And I think it's only recently that people have the language to put against that. And so again, the marrying of the data and the storytelling is something that we found really important.

A Patient’s Life Turnaround

Dr. Grundmann 35:38

Yeah, for that woman, her therapist, she'd gotten to the point where she was considering meds and they were gonna, they were talking through like things like pro-zaconomic medications. And her therapist literally went to her and said, I don't think you have time for that. I don't with how with how bad things are right now, with how depressed and and in a in that negative headspace she was. Her therapist literally says, I don't think you have enough time to wait for these things to kick in.

Mark McGrath 36:02

Well, Tiffany, get we'd like to hear your impression because Nico talked about this on on the other episode, but you know, you've hinted at it a couple of times, both of you, but you deal with patients and their team, not just not just the patient. I just can't walk in and say, hey, give me ketamine, I'm not feeling good. I mean, you you take a real collaborative approach across other professionals. Give us some flavor around that from your perspective.

Tiffany Franke 36:27

Yeah, this goes back to the initial debate Nico and I had around how are people gonna learn about us? What's the appropriate place? And really at the heart of what the care that we provide needs to be trust. Trust in us, trust in this medication, trust in the process. And we want people to learn about us ideally if they are connected to a mental health team through a trusted provider. So we really see ourselves as like a specialized service extension or provider tool for the mental health community who knows their patients intimately, who has their best interests in mind, and who can point to a tool that's gonna be highly effective in conjunction with a suite of other services that they might be providing, whether that's therapy, and there are so many different kinds of therapy, or whether that's other meds management, or whether that's activities that are gonna help them change behaviors to be more helpful. We will not get started with a patient until we have a third-party diagnosis of depression. That's very important. And until one of our care team has had the chance to have a conversation or close the loop with at least one licensed mental health care professional that's on the team. And that doesn't need to be a psychiatrist, that can be a therapist, that can even be a primary care physician if they're managing their mental health. And we know that the majority of antidepressants, for instance, are prescribed by primary care physicians. So they are, by definition, managing mental health. But this team-based approach ensures we're not the logical mental health hub or home for patients, but we are this place where we're the best at what we do. And we provide this very specific treatment, we're knowledgeable about it and how to make the most of it. And we know that for people to get the duration of benefit, to extend the benefit that is more effective in conjunction with therapy, where they can talk through things that might surface during the sessions, where during that neuroplastic window that's generated, they have the opportunity to engage in behavior change, whether it's how I talk to myself or whether it's habits of how I um when I go to sleep, when I wake up, you know, the little things that ex my exercise routine, the things that actually dictate how you feel through going through a day.

Mark McGrath 38:33

How how have, you know, the angle of, you know, I guess when I think of healthcare and medical, I just go right to bureaucracy and I go right to hospital systems and insurance companies and and everything else. How is navigating that been from your vantage point?

Postpartum Depression Breakthroughs

Dr. Grundmann 38:48

Uh this is my nerd part of the wheelhouse. It has been both much slower than we wanted and also much faster than we were ever expecting. It's this kind of duality. So, as Tiff mentioned, when we first started, we were thinking about five, 10 years down the line in terms of like what would need to be true for this to be something you could just go to your doctor and get as part of the normal healthcare system. And in 2018, no one paid for this. This was not an insurance-covered thing. And it was clear that with the generic nature of the drug, no one was going to push for it to be paid for unless it came kind of from within the people using it as a community tool. And then so part of why we've been collecting data the whole time is to change that. Like insurance does listen to data, it takes a lot of data. It takes the data being really clear about like the benefit and also the cost savings. It is less expensive to manage people's depression than it is to leave it untreated. And so we really wanted to put the groundwork in from day zero. So part of what Tiff has mentioned is that not only are we taking care of individuals day to day, but each one of those individuals is contributing to this data set that allows us to go and say, hey, Medicare, hey, Medicaid, hey, commercial insurance people, here's how this actually works in real life, and here's why you should pay this. And that has actually started to change. So two weeks ago, I got elected to the board of the American Society of Ketamine Providers. Um, it's a national group, 500 something members, and it's only people who do this. And I ran on a platform of getting this into normal US healthcare, getting this covered by insurance, getting this um approved on the regulatory perspective in an easier-to-access way. It's it's been a wild last year. We were in conversations with the FDA itself. We're in conversations with um insurance companies. We have one program going live in a couple weeks where people's employer, employer, the company, is gonna pay for this for their employees for a couple here in New York. We have this project we're building out with that ASKP group where they're gonna be applying to get Medicare to cover this here in the Northeast.

Mark McGrath 40:42

Um without give divulging sensitive details, I'd be curious if a company paying for its employees, is it a certain type of industry or whatever that would have a higher rate of depressed people?

Dr. Grundmann 40:53

No, I think that's the thing to remember is that depression just cuts across everybody. Yeah. And so it's 14% of the adult population would qualify as clinical depression, either major depressor disorder or bipolar disorder. That's like one in eight, one in seven people would qualify for this. And so every company knows that people that work for them are not at the and that's actually one of the things that's been so powerful the last couple years is we're seeing it change. Blue Cross Blue Shield, starting to pay for IV ketamine. You guys know from the last podcast, VA, starting to cover ketamine.

Mark McGrath 41:23

When the insur when the insurance companies get involved involved, would that endanger the prices for people that would pay out of pocket? Like does that push up their price to de facto, or if anything, it pushes it down.

Dr. Grundmann 41:35

Pushes it down. The biggest barrier to ketamine access right now is the fact that you have to pay out of pocket. Places that don't have insurance, so our services, for example, it's $550 a treatment visit with us. That is both really low in the sense of um 90 minutes of a doctor's time. It's like virtually free here in New York City.

Speaker 2 41:54

Yeah.

Dr. Grundmann 41:55

And at the same time, like most of the world cannot afford $550 a visit. The reality of people and their salaries.

Mark McGrath 42:03

And so And yet at the same time, you're delivering real value too. I mean, it is a it's a real value.

Dr. Grundmann 42:09

For sure. From a logic perspective, this pays for itself. If you can work, if you can function, there's there's no doubt it's worth it. But even when it's worth it, people often can't access it because they just don't have the upfront cash to do it. They don't have the ability. And so the way that that changes is this just becomes normal healthcare. Your insurance company pays for this. And if you have insurance, this is covered. Um, and that's the path we're starting to see pan out. Eight years later, a lot of the work that we've done has helped push this forward. But then your doctor gets paid like they would for any other doctor visit. You your team is able to do this as a recommendation for you, whether you have like no insurance or Medicaid or Medicare or commercial from your employer. That's where we want this to go because otherwise the 30-something million people who need this aren't gonna be able to get it if they all have to pay out of pocket.

Brian "Ponch" Rivera 42:55

There's an interesting parallel here to your background in consulting, Tiffany, that I want to bring up. Uh so it was brought up that the primary care provider generally provides medications, right? Just hands it out. To me, that's the old school consultancy, uh, creating that dependency for the client. Here, I'm gonna be here for you, I'm gonna do all these things for you. Um, that is opposed to what's happening now, where you're more of advisors, you're going in there, you're giving them things at work and allowing them to have self-care. And what I mean by that is they're not dependent on meds anymore. They, it's it's and by the way, this is not a one-and-done thing, right? This is a way to help them change behaviors, see the world differently, and move on. So change your orientation. That's exactly what's going on in that's what should be happening in the consulting world right now, is we got to reduce that dependency on the external environment or those meds that are out there. Um, and teach the organizations, the leaders, how to create their own capability to do this. And I think that's what you're doing in this space, is it's and I just realized that in this conversation today. I'm like, wow, you you're you're reorienting folks towards how this works. And because it's a complex adaptive system, it can be applied to other domains or other industries. So uh just a fantastic uh connection. I don't I don't know if you caught on to that today, Tiffany.

Adolescents And Safety Data

Tiffany Franke 44:07

Yeah, I mean, one of the things that I found so rewarding is bringing certain models from, let's say, design innovation thinking in my consulting world and applying them here in ways that perhaps they haven't been applied in this space. So the kind of focusing on the how. So an example there is before we even really started seeing a lot of patients, we did what we called patient archetyping, which is something that I'd done with many different clients. Who do we serve? What does value look like? What is the lived experience? You got to talk to people and understand and translate their their stories into an experience. And then what are all the details of care? And Nico and I did sticky notes on mirrors, right? What are all the tiny little details that are going to send a signal when you walk into the office for the first time and somebody greets you by name? Hi, Punch. It's a it's a pleasure to meet you in person. We've been looking forward to working with you. That sends somebody who feels like they don't merit the space that they take up, a message that they are worthy and that they are welcome. So, yeah, applying certain frameworks from the consulting world into how to create a distinctive experience and a service, which is essentially what we're providing to people in this care model, has been deep. Deeply gratifying and also breaking certain molds. Like I think even furniture in medical spaces, I think there must be a medical furniture supplier who creates, you know, kind of expensive, custom, ugly cabinets. And we say, well, why do we need to do that? Let's actually make it beautiful. Because when from a bureaucracy standpoint, he brought up that word, we're getting we get to make the decisions here. And that's not always easy because founding your own thing is very difficult. But we don't have to do things just because they've been done that way in the past. I brought a levels of listening framework in from my design innovation and organizational strategy days to design actually how we facilitate the 90 minutes in office. And that goes into our therapeutic communications framework of how our clinicians are engaging at different stages of the visit, level one, two, three, four, four being generative listening versus just kind of fact-collecting listening, which is how most people experience healthcare. So yeah, it's not just a widget that we're creating, it's an experience that we're crafting. And so bringing some of the best how-to tools from my toolkit has been really, really fun.

Mark McGrath 46:20

Well, I think uh one thing, the I guess the last thing as we as we get ready to close out here, uh, you know, Nico, you in fact do have a work wife. And uh Tiffany, you you have a work husband and it's not scandalous in any stretch. So that's uh phenomenal. Why don't you uh would be curious to get the perspective of what it's like to build something like this that's so mission-driven and so wonderful and providing value to so many people, and not just the patients, I mean the people that the patients touch, their kids and their spouses and their relatives and friends and things like that. But give us the give us the joys and trials. Uh, because I imagine it's not all, you know, sunshine lollipops, but what what are the joys and trials of working with your actual husband, your actual wife, and they are in fact your work wife, work husband, the first one?

Tiffany Franke 47:06

You can go.

Mark McGrath 47:07

Okay. We'll give Tiffany the last word, very, very wise strategy. Yes.

Dr. Grundmann 47:13

Honestly, it's just really nice. We we do everything together. As you've heard, we've got the seven-year-old and a four-year-old, we've got this ember thing. We didn't get into the story much, but Tiffany became full-time Ember Health back in 2020. So it's going on six years now that we've been able to walk into the office together. And the fact that we can share so much is really nice. That as Tiffers mentioned, it's it can be really hard founding something, starting something, running something. And that is true, even when it's with your best friend and partner. But the fact that I don't have to doubt that my co-founder is in it for the right reasons, and that if there's something that comes up, I can talk to them, and that we can really just like have absolute faith and trust that we'll be able to work through something and figure it out is really powerful. We we don't always see eye to eye. And as Tiffers mentioned, the kind of one thing that we both are involved in is the strategic side. Like I do the medical lead stuff, she does the people and and um experience stuff, but there are times when we're not necessarily in agreement about stuff. But even when we're not seeing eye to eye, the fact that we can actually talk through it, the fact that we can engage them with the very frameworks we treach our staff about. Like, how do you manage difficult conversations? How do you how do you actually work through some of that stuff in a way that we're not doubting that disagreement is gonna fracture anything? It's just gonna be something that we get to work through until we're both seeing eye to eye about what's best for the organization, for the people. Um, and have confidence that we can do that given the strength of our Tiffany.

Tiffany Franke 48:41

I think he said that pretty well. Yeah, I think it can feel precarious. Anybody who knows that if you're building something from scratch that has inherent risk, both of us, it was March of 2020 when I said goodbye for good to my full-time consulting job and went two feet into Ember Health. So our family, our young family with a nine-month-old, and you know, we had our healthcare and our livelihoods wrapped up in something new during a difficult time to navigate. So the precarity of is, you know, is this gonna work? And the ways that we want this to work, and both of our livelihoods are wrapped up in it and our, you know, our future together and our family's future is exciting. It can be challenging, it is really, really important. I think a lot of founders and a lot of CEOs, it can feel kind of lonely, you know, to have to shoulder a lot of the strain and the stress and the challenges by yourself. And we have each other. And when you come home and you've had a really difficult day, or a staff member decided to leave the team in in a way that make makes the, you know, it really difficult for everybody else, or there is an upset patient, or there might be any number of things, we get to turn to each other in the kind of vulnerable, you know, familiar personal spaces and be a shoulder, give advice, just listen. I think one of the things we've really strengthened is our communication skills together. And what's unflappable underneath there is our commitment to Ember and our commitment to each other. And we're able to give perspectives, I think, when it's necessary, which is always really important in a partner and come back to the fundamentals of what we're doing, which is there's a huge problem. What we're doing works, and we believe we're doing it the best that it's being done. So it can kind of put us back on track if there's a moment of stress and challenge. And we really believe in each other. Um, and that buoys anybody through through a day.

Mark McGrath 50:45

Punch, I think what a beautiful example and description of Einheit. John Boyd would talk about mutual trust, the way you guys function as a team, it's great. And you're building something that's, you know, you use the word beautiful, but it is really beautiful because when when people get, you know, life is beautiful, and you're helping people see that, and you're helping people in many cases get a second chance to recognize and realize that so they can stay here with us longer. I think that's really wonderful and across a wide panacea of people. So we're really uh we're really happy to know you. We're happy that you uh sponsor, we're happy to plug you guys when we uh when we release our podcast, including this one. Ember Health, of course, will have a nice uh plug in there. So Punch, any uh anything that I missed?

Brian "Ponch" Rivera 51:28

No, I could spend about 20 more hours in this conversation and uh I intend to uh reach out here soon. So thank you so much for uh joining us today. It's been an incredible conversation.

Mark McGrath 51:37

Yep. Thanks, uh Tiffy and Nico for coming back to uh to douway out. And Tiffany for your first uh visit here, which won't be your last, but the first buried couple to join us. We really appreciate it.

Team-Based Care Approach

Tiffany Franke 51:47

Such a joy, and we admire your work, and we know that it takes a lot of people linking arms together to make something work. And your support of us and what we're building has been so meaningful and giving us a platform to share our story. Thank you for the important work that you two do in your communities.

Mark McGrath 52:02

What a great way to close. Thanks, Tiffany and uh Nico, and hang on with us and then we'll uh we'll say goodbye to the uh to the audience. Thanks so much. Thank you guys.