At a time in everyone’s life, we come to find ourselves in a situation where the music stops, and we must go on.  The unfortunate truth about life is that the unexpected will happen. Some of us learn from it, some of us change because of it and some of us find our life’s calling because of it. The latter was the case for me.  After our dad picked us up from middle school, we spent that afternoon like we had every afternoon that month. We went to the oncology unit at the hospital, where my brother was admitted.



I remember him. I remember the man in the dark blue sarong the same way I remember the lines on back of my own hand. He was hunched over next to a column on a dirty platform at a railway station in Calcutta, India in the middle of the harsh summer sun. His hands were withered, his fingers and toes looked like tiny nubs, and he was completely malnourished and alone. He had opaque blue eyes, as if fog had taken place of his irises and pupils.



I studied insects in college; my favorite insects were the bees (I found them diligent and so helpful to humankind).  One of my favorite classes was about medical diseases caused by insects. My professors noticed my interest in the medical side of things and connected me with a professor who did clinical research. Our work focused on a clinical trial for children with intractable epilepsy and exposed me early on to patient care and patients.


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telepsychiatry, which can be used in group therapy rooms as well as physician’s offices.  For instance, one anticipated program is to assist obstetricians with the management of opioid addicted pregnant women. It is hoped that the high-risk pregnancy service will be able to identify these women clinically, manage them through their pregnancy with buprenorphine, while at the same time providing them counseling services with clinical social workers. This program also provides consultation and clinical management to obstetrical clinics in Eastern Kentucky. It probably will be too cumbersome for women in far eastern counties to come to Lexington on a regular basis for group therapy treatment. Our plan is to engage these women in telepsychiatry and enable them to participate in group therapy on a virtual basis. For instance, we plan to install a large wall monitor in the group room, which will interconnect to a referring obstetrician’s office. At the obstetrician’s office will be a dedicated computer linking into the proprietary telepsychiatry system managed by Dr. Burton. It will be used in the Transformation Care Clinic so that women in outlying counties can be seen virtually during the group therapy sessions taking place in the Transformation Care Clinic.

It is also expected that physicians at the St. Joseph East campus will be able to obtain psychiatric consultation in real time using telepsychiatry. For instance, we plan to install telemedicine rooms in the clinics that we serve so that physicians and clinicians can interact with the psychiatrist, psychologist, social worker or addiction medicine doctor in the clinic in real time and in virtual space.

The Clinic staff hopes that the Transformation Care  Clinic, in an effort to assist the St. Joseph Hospital East campus with the opioid crisis, will have telemedicine as an integrated part of this movement. We will integrate our telepsychiatry offerings within the guidelines of the new law approved by President Trump allowing telemedicine prescribing of controlled substances using DEA special registration. That legislation has been written by Congress and signed by the President.

The remaining offerings of telepsychiatry through the Transformation Care Clinic are expected to develop on an ad-hoc basis as the clinic develops and moves forward in providing clinical care to patients. Telepsychiatry at St. Joseph Hospital East is a work in progress, which will follow contemporary guidelines being developed at other academic sites in the United States. (2) We anticipate the provision of telepsychiatry to enlarge and improve the quality of outpatient services at St. Joseph Hospital East and to be part of the general movement in the United States to develop telemedicine as a concept in many medical specialties to provide care to those who are underserved and at great distance from specialists.


  1. National Council Medical Director Institute: The psychiatric shortage: causes and solutions, March 28, 2017. Washington DC, National Council for Behavioral Health, 2017. Available here.. Accessed December 2, 2018.
  2. Yellowlees P, Shore JH (eds). Telepsychiatry and health technologies: a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing: 2018
  3. Nochomovitz M, Sharma R. Is it time for a new medical specialty: the medical virtualist. Journal of the American Medical Association. 2018: 319(5): 437-438. doi: 10.1001/jama.2017.17094
  4. Hoffman P, Kane JM. Telepsychiatry education in curriculum development in residency training. Academic Psychiatry. 39(1): 108-109, 2015, 24477901.     

Part of this is being driven by the developing acute shortage of psychiatrists in the United States. As of April 2017, there were about 45,000 psychiatrists in the United States, with an estimated shortfall of about 6,000, which is projected to increase to 15,000 by 2025. (1)

Due to the obvious shortages in psychiatric manpower, more and more patients requiring psychiatric care are being seen in primary care as part of a “patient-centered medical home.” In this scenario, the primary care physician becomes the  coordinator of care, and this relationship is occurring partially in response to the shortage of psychiatrists. (2)

The role of psychiatrists in particular, is expected to change as these practitioners increasingly take on roles as clinical leaders, teachers, and mentors for teams of providers. This will be as both seeing individual patients and managing populations of patients while using mobile, easily accessible systems that are patient-centered and flexible. (2) A new concept of specialty care using telemedicine concepts is that of the medical virtualist. (3) However complete replacement of the traditional clinical encounter will not occur. “Bricks and clicks” will prevail for patients’ convenience and value. Physicians will lead teams with both in-office and by rote monitoring resources at their disposal to deliver care. This model could be enhanced in the future with digital assistance or avatars. (3)


The medical virtualists will need specific core competencies from curricula that are beginning to be developed at some institutions. Psychiatrists lag behind compared to some other specialties in the development of this technology in residency training programs. A 2014 survey of 183 U.S. residency training programs found that only 21 offered any training or experience in telepsychiatry, and often this was only an elective offering. (4)

The author of this article is currently developing a new concept in psychiatric outpatient treatment at St. Joseph East Hospital in Lexington. This is spearheaded by Anna Bennett, RN, Director of Surgical Growth Opportunities at St. Joseph Health System, and Edwin Nighbert, M.D., Chief Medical Officer. The new clinic is called Transformation Care and will include services of neuropsychiatry, psychiatry and addiction medicine. It will also provide consultation services to numerous outpatient clinics at St. Joseph East Hospital, including neurology, pain medicine, oncology, and high-risk obstetrics. Deborah Burton, Ph.D. acting as Manager of Telehealth in the Strategy and Business Development Section of Kentucky One Health, is assisting the Transformation Care Clinic with integration of telepsychiatry into its services.

The new clinic is expected to have a mobile communication system for


Robert P. Granacher, Jr., MD, MBA practices clinical and forensic neuropsychiaty in Lexington and Mt. Vernon, KY. He is a noted scientific author and past president of the Kentucky Psychiatric Medical Association. He is currently president-elect of the Lexington Medical Society and Clinical Professor of Psychiatry at the University of Kentucky College of Medicine.