In his journey to becoming one of the country’s most admired diagnosticians, physician Gurpreet Dhaliwal has utilized years of training, online tools, a computer-caliber memory and good old-fashioned gut instinct. Dhaliwal, who has been compared to the fictional “House M.D.” for his talent to pinpoint a patient’s disease with almost superhuman sensitivity, earned this rave from the New York Times: “To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course.”
But Dhaliwal, a friendly, self-effacing and upbeat 39-year-old associate professor of clinical medicine at the University of California San Francisco, feels that a skill like his is not out of reach for any bright, curious healer.
Dhaliwal is often consulted by other physicians baffled with their own cases, and he speaks at medical conferences, where he is given a list of symptoms and, quiz-show style, comes up with a diagnosis on the spot. The Indian American doctor spoke to India-West at his office at the San Francisco Veterans Affairs Medical Center.
Q: I was reading about the way you diagnose and I was reminded of the way a policeman might interrogate someone — it’s almost like they’re watching everything but the words.
A: Yes, the analogy between a detective and a diagnostician is an apt one. There’s a basic set of clues that you might think is obvious, like basic patient data, numbers and physical exam findings; but if you’re a skilled observer, there’s a lot more context. These are things like the person’s social situation, their general appearance, their facial expressions as they respond to your questions and the things you say. There’s much more to analyzing and diagnosing a patient than comes in the raw data stream. The picture of the person in their world is so much more complicated.
People underestimate that. Diagnosis, they think, is an interpretation of medical facts, but the communication and understanding of the patient’s world is often where the clues lie to solving their cases.
I recall a patient who kept coming to the hospital with asthma, over and over. In many ways it seemed like asthma, given the wheezing and shortness of breath.
We gave the patient all the proper instructions, but he would come back with the same breathing problem. The typical assumptions were that the disease was very refractory, or the patient was not taking the medicines as we prescribed.
But when we were in the room, we noticed a number of things that the person was reading. Among them was a book on birds. It was sitting on his bedside in the hospital; when you’re sitting in the hospital, there’s a lot of time to pass.
I came to ask, “Do you have birds?” He said, “Yes, I do, I’m a great aficionado of birds.” As it turned out, the reason he was getting short of breath was not because of asthma, or because of a problem with his heart; it was a condition called hypersensitivity pneumonitis. That is a reaction in which people’s lungs become more sensitive to bird antigens.
Q: You seem to be versatile and capable of so many things — so why teach, instead of just working in your field?
A: Teaching is my first love. I never envisioned being a doctor without being a teacher. The name “doctor” derives from the Latin word for “teacher.” Many of us know the two to be interlinked concepts. Many people, and I count myself in this group, become better doctors when we teach the craft instead of keeping it to ourselves.
A: Because you have to articulate your thoughts, you have to examine your own assumptions, and you’re definitely kept abreast of the latest developments when you are teaching very smart learners. And it makes it more fun.
Q: Is there ever a danger of accumulating too much data?
A: Yes, there is a risk – when you look at studies about people who diagnose well, they don’t collect more information. Because their brains have solved these problems before, they know the proper information to collect. They know the questions that will lead to a pivotal answer.
“Do you or don’t you have a bird at home?” That’s a very binary question, but only if you’d seen hypersensitivity pneumonitis before would you ask it. Experience allows you to ask those questions that might seem to be non sequiturs.
It’s fine to say someone is a great diagnostician; I’m more impressed to find that someone is an ever-improving and resourceful diagnostician.
Q: What is it like working in a military context, here at the VA Hospital?
A: They are all civilians at this point, but they were all military in the past. It is such a powerful, moving experience to hear their stories. I’ve been at this hospital for 12 years and it’s an honor to take care of the veterans.
There are so many dimensions of this patient population that are rewarding. They are incredibly giving, and really willing to allow our students and residents to learn from their care. They’re wonderful patients who want to be partners in their care and they’re willing to share decision-making with their doctors.
You could ask, “What do you get out of taking care of a population like this?” You almost get a sense of giving back to someone who has given so much to America. One of my favorite quotations on the wall of the VA is “The price of freedom is visible here.”
The stories you hear — I’ve taken care of survivors of Pearl Harbor, chauffeurs of presidents, cryptographers in Vietnam. For every era in this country’s military history, there’s someone here who has been close to the action. Sometimes we get the inside story that doesn’t get into the history books.
Q: Tell me about the Indian side of your life. Were you born in India?
A: I was born in Wisconsin and lived in the U.S my whole life. I grew up in the Midwest, where 99 percent of my family still lives, in Wisconsin. My younger sister is an architect living in Brooklyn with her husband and son. I live in San Francisco.
India is certainly an important part of my identity. In a medical setting, there are a large number of Indians here so it’s easy to find colleagues from the same background. But also, living in the Bay Area, there is so much Indian culture around that it’s very easy to take in as much as one would like. Our last trip to India was in 2009, and three generations went: my parents, my sister and her husband, my wife and our two boys.
We are Punjabi Sikhs; both of my parents are physicians. My parents did a wonderful job of teaching us both worlds. We assimilate marvelously in America but we grew up knowing everything about our religion, our food, and our culture from them. I admire how they balanced both worlds.
Q: Were they close to the gurudwara in Wisconsin that had the shooting?
A: That actually was our family gurudwara. It was the Sikh community that we grew up in, so that was a major event for our family. We were close to many people who were affected — that whole Indian community is our community.
Q: How do you feel about Ayurveda, homeopathy or other modalities used in India?
A: At the veteran’s hospital I have not encountered many patients who use Ayurvedic medicine, but as far as other forms of complementary medicine, if it works for a patient and it’s safe, then I think it’s completely fine. I endorse it wholeheartedly. Something that has worked for thousands and thousands of years must have value — I can’t predict which patient it will have value in. I’m never one to turn someone away from it, and if I hear that it’s working, I’ll tell someone to stick with it.
Q: Give me an idea of what kind of hours you work.
A: I am at the hospital 45-50 hours a week but I also get up early every morning to do additional academic work or preparation for teaching. I love it.
When I give a report of how many hours I work, I say it with joy. I love what I do. I am incredibly lucky to be working at a veteran’s hospital, working with people who served, I have the chance to teach very bright and intellectually curious students and residents, and I have this highly intellectual environment at the university and I sometimes wonder, how can it get any better?
Q: And you have San Francisco outside your window.