HIStalk Interviews Joseph Pocreva, MD, Colonel, US Air Force

Joseph Pocreva, MD is an emergency physician at Keesler Medical Center at Keesler Air Force Base, Biloxi, MS. He is a colonel in the United States Air Force. His views and opinions are his alone and do not necessarily reflect the official policies or positions of the Air Force.

Tell me about yourself and your job.

I’m an emergency medicine physician. I’ve been practicing for about 15 years. I am in the Air Force. I have been working in various emergency departments, Special Operations, and different areas of the Air Force.

I have been here at Keesler for approximately five years and have had various roles while I’ve been here, including flight commander, medical director, and a practicing doctor on the floor.

How much of your career is more military than medical?

Sometimes it’s not very easy to answer that question. There are some physicians who feel like they’re more doctors than they are officers. Some feel they’re more officers than doctors. I have felt both ways.

Obviously when I’m on the floor and I’m engaged with patients, I’m a doctor. Yet when I walk away from the floor, I have to interact with other places, not only in the hospital but throughout the Air Force or with engagements with the Army or the Navy. Then my role oftentimes becomes more of an officer in the Air Force. That’s in my current position.

I’ve had other positions where I had no medical role at all. It was all about being in the military and functioning as an officer. It is a switch that gets toggled quite frequently. I’m not sure if I answered the question very well. I wouldn’t be able to give you a 60 percent, 40 percent answer — it all depends on the day and the demand.

You served on a humanitarian mission to Haiti, correct?

I was in Haiti. That was in 2010, just months before I was assigned here. I was the lead medical officer in Haiti when we went into the country to open up the airfield.

Have you had other assignments or deployments to other locations?

Oh, yes. If you’ve spent any time in the military in the last 20 years, you will have deployed.

My initial assignment was at Eglin Air Force Base in Florida. I deployed to Iraq in that timeframe. I was also stationed at Hurlburt Field, which is the Air Force Special Operations base. I did a lot of shorter missions, primarily to the Philippines. That’s where I went to Haiti as well.

I’ve traveled quite a bit doing a lot of diverse things. A lot of forward medicine, dealing out in the field without a lot of hospital support, just “what I can carry on my back” type of medicine.

How have you used that front line experience from Iraq in your ED job?

I was in a forward hospital there. We had a pretty decent sized staff, but we didn’t have a lot of resources. Practicing emergency medicine in today’s world is very lab- and radiology-intense. In those settings, we just don’t have those kinds of resources. You have to rely on your clinical abilities and your ability to make a decision, which is oftentimes paralyzing to the younger clinician who depends a lot on labs and radiology and their consultant staff.

If you don’t have it, you have to make decisions. Your decisions have serious implications, because if you want to transfer somebody in that setting, you have to get an aircraft to come in and take your patient away. If you can take care of them there versus putting them on a very expensive aircraft … You have to make those kinds of decisions. There’s a lot of differences between forward medicine and medicine back home.

What it’s like practicing in an Air Force hospital ED versus a civilian one?

Some very important key differences. We practice socialized medicine. We have a very captive patient population. They all have primary care doctors. They all have access to medications. There’s a social structure which is well defined. All of our active duty people have supervisors who we can call.

It’s a very different world from the outside. I’ve worked on the outside as well. I’ve moonlit for years at many different institutions and things.

There are advantages and disadvantages to both settings, but working inside the military is what socialized medicine is, in a nut shell. Actually, I would go on to say that, as far as I can tell, it is the best example of socialized medicine that we would be able to maintain.

People forget that military medicine isn’t just taking care of active service members, but their entire families as well, so you have pediatrics, oncology, and other services.

Right. The active duty population is only a small portion of who we take care of. The majority are their dependents and then our retirees as well. It’s everything from cradle to grave.

Is military medicine care at least comparable to what is offered in civilian settings?

It is somewhere in the middle. I’ve worked in plenty of hospitals that had nowhere near the capability that we have. Then you go to some of the major medical centers which have comprehensive care … When we have patients that are beyond our capability, then we will refer them to, in our case, the University of South Alabama or the Jackson Medical Center up in Jackson, Mississippi or over to Ochsner in New Orleans. We rely pretty heavily on them.

As far as the bread and butter basics of medicine, into surgery, into your medical specialties, and what have you, what we have is quite comprehensive.

What technologies and IT systems do you use in your practice?

We have CHCS, which is our basic underlying database., It’s been in place since the late 1980s and we’re still using it to today. That is where we record all of our labs and radiology and that’s where we do our prescribing from. As old as it is, it’s solid as a rock. It never goes down, ever. Everything else can go down, but CHCS still manages to keep plugging along.

On top of that, we have a graphical interface software solution called AHLTA. When it works, it works all right. [laughs] It is a program which is designed to interface with CHCS and pull data from it, as far as all of CHCS capability. But it’s also for record-keeping and and electronic medical records. We use it primarily just as an interface to get to the CHCS data.

In our emergency department, for our recordkeeping, we use T-System, which is hands down much better when it comes to data entry than AHLTA is. Much, much, better.

Those systems may be replaced in the DHMSM project. Are you looking forward to that or concerned by it?

I don’t really know a great deal about it. I understand that Cerner won the contract to provide the next generation. There’s generally the understanding that it’s going to be coming sometime in the future. After that, I think I know enough in my career that I don’t get too excited about dates of when it’s going to come, so I don’t know when we’re going to actually see that.

I would be very surprised if it has an interface which is more user friendly than T-System. Hopefully we can find a way to integrate T-System into it. But beyond that, that’s just all conjecture, and I don’t know — I’m not a part of that whole process.

I’ve read that 60 percent or more of care delivered to military members happens outside of military facilities. How do you communicate with external providers?

That 60 percent probably reflects most of the places not around the larger institution. Around here, we probably deliver considerably more than that in our facility. But so many of the smaller bases have been reduced to clinics. A lot of that referral work and surgical procedures and things are going to be done on the civilian side, so I think we do a great deal more of it here.

However, when we do refer people out to the community, they are not on our informatics databases. We have to rely on them doing a consultation and sending the reports back to us. Then our information people enter that data back into our system. It’s a rather slow and cumbersome process.

Do you have a lot of overlap in the information that you either need from or provide to the VA?

No. We see a lot of VA patients. We have a pretty robust interventional cardiology practice here, so virtually all of their cardiac caths come here. We have a lot of vascular surgery. A lot of the VA patients come here, but we don’t use their systems, nor do they use ours. If we want that data, we’ve got to go and request it old-school style.

How long do you plan to stay in the military?

I have been in the military for 23 years right now. I will be getting out next year. I’ve already put in my paperwork to retire. I should be retiring somewhere around the first of August in 2016. I will likely be joining a local practice here in the area.

What will you miss in not being part of the military?

The people, without a doubt. My grandfather was career Navy. My father was career Air Force. I’ve been on the Air Force welfare system since I was born. I don’t know anything different.

Not only taking care of this population, which is something that is very important to me, but working alongside a lot of people who really care about being here and doing the mission and being part of something much bigger than themselves is one of those intangibles that is very difficult, if not impossible, to find anywhere else.

It will be a sad transition for me, I’m sure. Although the local hospitals around here are wonderful by any marker, it’s going to be difficult to walk away from an institution like this.

People with no military connections admire the patriotism, discipline, and sacrifice involved. Is it equally impressive from the inside?

Oh, yes. Yes. You see people with talent and abilities and what have you. You look at them and you think, "Man, you could be making a million dollars on the outside, and yet you’re in here doing this job.” I really appreciate it.

That really comes through and shines when we’re deployed. When you’re out there and you’ve been away from your family for a couple of months and people are still putting their shoulders to the grindstone and just working hard.

Sometimes the situation and the environment we’re in is less than ideal. We’ve yet to go and occupy a really great place. [laughs] We tend to deploy to less-than-ideal locations. It’s very impressive when you see people step up and do the amazing work that they do. It’s an honor to be a part of that.