Episode Transcript

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs. Hello, this is Daniel Lobell with the Doctorpedia podcast, and I am so excited today and honored to have joined with us, Dr. Chhavi Gandhi. How are you?

Dr. Chhavi Gandhi: (00:33)
I’m so well, thank you. I feel honored to be here.

Daniel Lobell: (00:36)
Thank you very much. And what a cool name? Can you tell me a little bit about it?

Dr. Chhavi Gandhi: (00:41)
[Laughs]. Sure. So my parents are from India and moved here in the seventies, kind of thinking that they’d come here for a few years and maybe have children and then move back to India. And so they picked a very traditional Indian name. My mom had known somebody with that name, and really liked it. So she wrote it phonetically with kind of Hindi translated into English, so that as you’ll notice, there’s two H’s in there and it tends to confuse people, but that is the phonetic way to translate it. The name means image or reflection, and it’s been nice to have a name that not everybody has, but it’s been a little bit of a conversation piece [Laughs], I should say, growing up.

Daniel Lobell: (01:24)
It’s unique and it’s cool. And it’s certainly something to reflect on. [Laughs].

Dr. Chhavi Gandhi: (01:29)
[Laughs]. Absolutely.

Daniel Lobell: (01:29)
It’s in the name, you know, you’re going to have to reflect on a name that means reflection, right?

Dr. Chhavi Gandhi: (01:35)
There you go.

Daniel Lobell: (01:37)
But did your parents never go back to India? Is that what the implication was?

Dr. Chhavi Gandhi: (01:41)
Yeah, they came here in the seventies and I was born here and then my dad thought this place was too good to leave. And he and my mom have stayed here now for over 45 years and love it and have gone back and forth to India several times to visit, but have been living here since then.

Daniel Lobell: (02:02)
They discovered Costco or something like that. [Laughs].

Dr. Chhavi Gandhi: (02:05)
[Laughs]. It might’ve been pre Costco time, but yeah.

Daniel Lobell: (02:09)
So, what part of America did they settle in? Where are you from?

Dr. Chhavi Gandhi: (02:14)
So I was born and raised in Chicago where they first landed in America. And then I was raised in the Chicago suburbs. For most of my life, I stayed in Illinois. Then I moved to San Diego for a few years to do my internal medicine residency, chief residency, and my allergy immunology fellowship, and then came back to my hometown. And I’ve been back in the Chicago suburbs now for 11 years and very close to my parents, which has been a lovely experience for me to have children here and have their grandparents close by. So it’s been lovely.

Daniel Lobell: (02:53)
It is a huge testament to how much you love your parents that you left San Diego. [Laughs].

Dr. Chhavi Gandhi: (02:59)
[Laughs]. Well, every February I question my sanity when I’m here in Chicago.

Daniel Lobell: (03:04)
[Laughs].

Dr. Chhavi Gandhi: (03:04)
But it’s really a testament to my husband who is a California native that I met in residency and he moved to Chicago with me. So I give him all the credit for coming out here with me. [Laughs].

Daniel Lobell: (03:15)
So tell me a little bit more about your parents. Were they in medicine as well? What inspired you to get there?

Dr. Chhavi Gandhi: (03:21)
Yeah, so my dad was in medicine. He’s a retired psychiatrist and had moved here initially to finish off his residency and then had a thriving practice in the Chicago suburbs and was very well-respected and ran a really great practice full of doing the right thing. So he always put patient care first and was a very kind, and still is a very kind and decent human being. And I always watched him, he worked very long hours. He would work 13 days in a row and take a day off. And in fact he discouraged me from going into medicine. I had not really thought much about medicine. I knew I was doing very well in school and I loved science and I wanted to help people. And just suddenly when I got into the planning of college decided, “Yeah, I think I’ll try this pre-med thing and see how it goes.”

Dr. Chhavi Gandhi: (04:17)
And frankly my parents were not overjoyed by that. [Laughs].

Daniel Lobell: (04:21)
Really? Wow.

Dr. Chhavi Gandhi: (04:21)
Yeah, I think it was because my dad worked in a low income area. He worked very hard and we were very comfortable, but it was not a cash cow or anything. And I think he was trying to figure out how that would work out for me as somebody who wanted to be a wife and a mother, and to balance out my life. So I ended up meeting groups of friends in college who were pre-med and they’re still some of my best friends and got into medical school. I actually loved learning about pathophysiology and loved medical school, loved learning about the body and loved helping people. Once I got there, I realized it was the right fit for me, specifically with allergy immunology – I think I realized it fairly early on in medical school, when we started our clinical rotations: Initially they have us rotate in pediatrics and adult medicine, and I liked them all.

Dr. Chhavi Gandhi: (05:14)
I had a really big love for being around children, but I had a hard time with the hospital aspect of seeing kids being so sick. I did internal medicine and adult medicine. And while I was there, I had the opportunity to shadow some people in allergy immunology, which is a unique field where you can go into it, whether you’re adult trained or pediatric trained, because the fellowship that I was in trains you for both pediatrics and adult allergy immunology. And so I got to work in both and loved it. My personal background and probably what drove me to it was that I was a child with a lot of allergy and looking back, I suffered a lot, we just didn’t know a lot about it. And even with my dad being a physician, we just kind of did our thing, but I had severe asthma and really bad nasal allergies. I now recognize all the limitations that had on my ability to perform in physical education, sports, and just the outdoors as much as I wanted to. And so it just became a really good fit for me where I realized like people’s lives are very much impacted by this, even though they think it’s just sniffly noses. I had a passion for it and felt very grateful to be able to pursue a career in it. And I absolutely love what I get to do.

Daniel Lobell: (06:38)
Yeah, absolutely. And I grew up with a brother who suffered terribly from allergies and asthma. I imagine there must be a connection between them.

Dr. Chhavi Gandhi: (06:47)
Oh yeah. So they all are on the same spectrum of genetic illnesses – food allergies, asthma, nasal, or eye allergies and eczema are all thought to be linked from the same genetic kind of material. And so if somebody has one of those, they’re at an increased risk for all of them. If a parent has one of them, the child has an increased risk for any of them. And so they do go hand in hand. There is sometimes a pattern that we’ll see with children, like what’s the first thing that leads to more. So yes, asthma and nasal allergies go together, quite often.

Daniel Lobell: (07:24)
What’s interesting to me is that my brother still has asthma and eczema, yet his food allergies are gone. He used to not be able to eat sesame or eggs or salmon, or I think at one point chocolate as well, and now he can eat all of that. So what happens to a person where they can go from such a severe allergy to no allergy on things like that?

Dr. Chhavi Gandhi: (07:53)
It’s a great question. It really depends on the specific foods. There are some known foods that present early in childhood that the majority of people will outgrow. And those tend to be things like cows’ milk or dairy, eggs, soy and sometimes even wheat. The sesame, which are the seeds, and the tree nuts and fish allergies sometimes hang on longer, but there are people who do outgrow it. And the biology behind that can be tricky to figure out. We used to think most people would outgrow their milk and egg allergies, and that’s still the truth or the fact of the matter, but what we see is that there are still some people who are maintaining those severe allergies into adulthood.

Dr. Chhavi Gandhi: (08:39)
So there is some tolerance that’s being built naturally in the body that starts to accept some of these foods. It has a lot to do with antibodies that are triggering the allergic reaction and that may still be there, but we also build some tolerance, antibodies that kind of dampen the response. And those tend to kind of flip roles as people get older. So the allergic antibodies will go down, but the tolerant antibodies will build up over time. Then there are things that allergists will do to try to help that along in some patients, depending on the particular food to make that happen faster by building tolerance a little earlier, but I’m happy to hear that your brother’s food allergies have gotten better because those are very limiting in people’s lives on a day-to-day basis.

Daniel Lobell: (09:28)
Right. And in contrast to your point, his wife is still allergic to nuts, so she can’t eat nuts even in adulthood.

Dr. Chhavi Gandhi: (09:36)
Yeah. And that’s more of what we’ll see. We will see that the tree nuts and peanuts will persist per long-term compared to the ones that we talked about before. So I’m happy to hear that about your brother and like nothing’s a hundred percent for anybody. We are open to saying that every person is an individual, and that’s why we assess people individually. We have general rules of thumb of how things go, but every individual behaves in their own right. And so they deserve a workup and an explanation from a physician to see what’s going on.

Daniel Lobell: (10:07)
Yeah. You know, you were talking about when you had all those friends in pre-med, I consider myself pre pre-med.

Dr. Chhavi Gandhi: (10:14)
[Laughs]. Okay.

Daniel Lobell: (10:16)
[Laughs]. So I do think sometimes in a more medical way, and in light of that, as you’re speaking, I’m thinking about COVID and I’m thinking about the vaccines and we keep hearing about the vaccines and how they build resistance to antibodies. And I think that’s my understanding of it. Is there some concept of vaccines for allergies to nuts or something like that going on?

Dr. Chhavi Gandhi: (10:48)
So good question. They’re kind of different. They both work in the immune system, but they work in slightly different ways. So we talk about allergy in four different, big categories. One of them, which is when we’re talking about foods, is what we call an immediate hypersensitivity reaction. So it’s one where you have pre-made allergic antibody that if you’re exposed to that agent, and this actually holds true even for airborne allergens. So if somebody has a dog or a cat allergy or a pollen allergy, it’s the same type of process where we have pre-formed allergic antibody, which we call IgE. And when we’re exposed to that IgE, our body then sets up a cascade of reactions where it brings in all of its friends to give you what you’re feeling as your allergic reaction and in the case of food, that reaction can be life-threatening if it escalates enough.

Dr. Chhavi Gandhi: (11:44)
And so that is why, for people with food allergies, the first treatment is avoidance. And the second treatment is to have your epipen ready or epinephrine injector ready to use, because that would reverse that kind of cascade. So there is currently no immunization or injection that we have, that would specifically target food allergies. There are several things being looked at, that are being used for things like hives and asthma that are injectable and that are also being looked at for food allergies to see what they would do, but there is nothing that’s FDA approved or that we’re using regularly. What you might have heard of are therapies called oral immunotherapy, also known as OIT. And there’s also sublingual immunotherapy where doctors can give patients very small doses of the offending food with the goal of getting their body more tolerant to higher and higher doses. This does not cure them of their food allergy but in the majority of cases, it allows them some tolerance to accept a certain amount so that if they had an accidental ingestion of say, some peanuts, it would not cascade into that large reaction.

Dr. Chhavi Gandhi: (12:53)
If they were eating eight peanuts a day and they ate one accidental peanut, nothing should happen. And so that’s where we’re at with the best kind of immune treatment right now. Now those patients, if they lapse in having their daily doses for a certain amount of time, they are at risk of having a reaction upon re-exposure. So nothing there is long-term just yet, but we’re hoping there’s more and more treatments coming about. There is currently an FDA approved peanut protein oral immunotherapy that works in the same way, that just recently got FDA approved last year. And I think things kind of got put on hold for us at the office with instituting it because of COVID. But there are things in the works. Now, vaccines separately, when we’re talking about for COVID or any kind of illness are done very differently. So this works through a separate kind of compartment in the immune system where the goal is that you expose the body to some portion of the virus, with the goal of getting your body to recognize that and build antibodies to that particular signal, so that if it encounters it in real life, it is ready to go with its army of cells to attack it, kill it, and get rid of it. That is basically what all of our viral vaccines tend to do.

Daniel Lobell: (14:17)
That’s what I was thinking. What is it about peanuts? I mean, growing up, I never had peanut allergies and I’m just thinking about Mr. Peanut with his monocle and his hat.

Dr. Chhavi Gandhi: (14:29)
[Laughs].

Daniel Lobell: (14:29)
And how he always seems so unassuming to me, but to so many people, he must be such a sinister character.

Dr. Chhavi Gandhi: (14:37)
It’s so funny because I joke with my patients who are more my age, like in their forties. And I say, when we were kids, if you missed your school lunch, they would give you a PB and J sandwich, right? They always had some in the office. And now that would be sacrilegious in school. So there’s a lot of research as to why, the ‘why’ is really important because if we find out the ‘why’ we can start figuring out how to get rid of it or attack it from the start. There’ve been several different hypotheses. You’ll hear things like the hygiene hypothesis. There’s also conversations about biodiversity. The hygiene hypothesis implicates that we, as a society, are a little too clean. Our bodies are not exposed to enough illness and bacteria and pathogens. And the same cells that actually trigger allergy, in some cases fight off infections. Some of our allergic cells are there also to fight off things like parasites. And when they don’t get the opportunity to do that, there are some theories that they’re latent and sitting around and they do this. Now, that whole hypothesis hasn’t really panned out. There have been studies on it. And I don’t think it’s been a hundred percent rolled out, but it hasn’t really been proven that that’s what’s happening.

Daniel Lobell: (15:55)
My biggest question is “If you look at countries that are less clean, are they also suffering less from peanut allergies?”

Dr. Chhavi Gandhi: (16:08)
That’s where I think it started from, because if you looked at third world countries previously, that was the case. But now that the countries are becoming more industrialized, we don’t see that dichotomy as much. We’re still seeing now countries like India, for example, where peanuts and tree-nuts are eaten very early on in life and no one really saw a whole lot of it. But when you looked at the wealthy and you looked at families who had more means, we saw more prevalence of that. And now I’m seeing a lot more allergy in India than I used to. But in general, we’re not sure if it’s more to do with hygiene or if it’s more to do with industrialization – there’s a lot of kind of ideas about it. One thing we do see though, is that people who have exposure to farm animals or who have been raised on farms or have a lot more of biodiversity of the different things they’re exposed to tend to have less allergy. So it seems like patients coming from more of a rural setting with lots of plants and animals tend to do better or have less frequency of prevalence of food allergies than those who are in a more urban setting.

Daniel Lobell: (17:12)
So it’d be rare for someone to grow up on a peanut farm and be allergic to peanuts.

Dr. Chhavi Gandhi: (17:17)
[Laughs]. I’m going to venture and say yes, but I don’t know that for a fact. [Laughs].

Daniel Lobell: (17:22)
[Laughs]. Otherwise you’re growing up in hell.

Dr. Chhavi Gandhi: (17:23)
[Laughs]. Yeah. [Laughs].

Daniel Lobell: (17:29)
[Laughs]. You mentioned that there are some things that are coming up the pipeline. Is there anything that’s exciting or has you excited in terms of allergy treatment?

Dr. Chhavi Gandhi: (17:44)
Yeah, I think what we’re speaking of with food allergies, there has been some on and off work on different ways to deliver food. One we’ve talked about is orally and there are also sublingual drops. There’s also been some testing of the peanut patch, so it would deliver it through the skin and it showed some promising early data. I know it’s been on and off through FDA approval process and so we’re waiting to see that. And then I think the next arena we’ll be looking at is some of these medications that we’re using. They’re biologic, injectable medications we’re using for patients who have asthma, hives, really bad eczema, and seeing if they have a role in treatment for people with food allergies. The tricky thing there is that food allergies can be avoided by not eating and the accidental exposures are there as a risk, but if you don’t eat it, you’re usually doing okay. So it’s kind of a balancing act of how much do you need to push it with medications if your patient is not actively having those symptoms. We’re always excited to see the next great thing that scientists are working on. I’m certainly ready for more to be available as well for our patients.

Daniel Lobell: (19:01)
Sure. How much of what you do involves the knowledge of nutrition, because there’s so much to do with food?

Dr. Chhavi Gandhi: (19:08)
Yeah. That’s a fantastic question. I think in what I do specifically, there’s a lot that we have to learn about nutrition and understanding labels and cross-reactivity and how foods are labeled because there’s often several different words used for the same exact allergen. I will tell patients who have egg allergies, “Hey, be careful – a certain candy that you never would have thought has egg in it, actually has egg in it.” And so it’s just about a lot of education. I have partnered up with a nutritionist. I have a lot of patients who have multiple food allergies and it’s very challenging for them to figure out what to feed their family or what to feed their child. It’s a fantastic resource to have a good registered dietician, who knows how to work with families with those issues.

Daniel Lobell: (19:59)
Yeah. I was just think about the reaction that a little thing, like a peanut, can cause in somebody and how mindlessly we eat. What are we doing to ourselves with the many things that we put into our body, especially all those chemicals that you see in the ingredients of some of these processed foods that you eat, like what are we putting into ourselves and what is it doing to us? And how is that making us react to the more holistic foods, the more natural foods? I know that you’re a big proponent of holistic medicine, and I just wanted to hear a little bit about what holistic remedies you found for allergies, if any.

Dr. Chhavi Gandhi: (20:54)
Sure. I think the word holistic has got several meanings and for me, when I talk about it, it’s using a whole body approach. So it’s a whole life approach and thinking about all the aspects of health. As you mentioned already, nutrition’s really important. Knowing what you’re putting in your body, knowing if you’re eating a lot of processed foods, versus cooking at home, or getting food from a restaurant where you know what’s going in there, exercising, making sure that you have a balanced diet. And also looking at things like vitamin D levels and making sure that people are in a good place with that. What’s really important for me is identifying triggers for patients. So be it for asthma or nasal allergies, even for hives in some cases, allergies are a trigger.

Dr. Chhavi Gandhi: (21:43)
We do testing with the goal of getting patients’ knowledge about what things are safe for their body and what things are not helping them. And then really providing them with the ideas of what they should be limiting from their exposure and how to be able to do that. And in doing that, there’s some things patients are allergic to, like dust mites, that are present in every single person’s home, regardless of how clean they are.

Daniel Lobell: (22:10)
Not mine.

Dr. Chhavi Gandhi: (22:10)
Not yours. [Laughs].

Daniel Lobell: (22:10)
[Laughs].

Dr. Chhavi Gandhi: (22:10)
And that’s why I always have to lead in with, “No worries. It has nothing to do with how clean you are,” – because the moms look at me like, what am I saying, microscopic bugs, right? Microscopic bugs that you can’t see and they live in mattresses and pillows, and we breathe them in every single night. And if you’re not allergic, nothing happens.

Dr. Chhavi Gandhi: (22:30)
But if you are, it can cause a whole host of problems. And so we’ll talk about how to get special covers for your mattress and pillow, how to eliminate those exposures, all sorts of things. I think it becomes a whole body approach. I end up talking about the home environment, quite a bit about their lifestyle and what they do with eating and how much they’re exercising and how much water they’re drinking. And so we end up approaching it from multiple angles, because it all tends to kind of interact with their health. And especially when we’re dealing with allergies, it’s very important.

Daniel Lobell: (23:04)
Yeah. I mean, it’s very interesting; it’s making me want those covers for my bedsheets.

Dr. Chhavi Gandhi: (23:10)
[Laughs]. Come visit Chicago and then we’ll take care of you.

Daniel Lobell: (23:15)
[Laughs]. Yeah. What about the masks we’re wearing from COVID? Are those protecting us from dust mites at least?

Dr. Chhavi Gandhi: (23:23)
Oh, good question. You know, I have not looked at this very closely. It really depends on the weave of the fabric that you’re wearing. So when we talk about dust, my covers have to be tighter than about two microns because that’s the size of a dust mite. So it really depends on your particular mass and, and keep in mind, dust mites are not flying around in the air. So when you’re sleeping, they come up to the surface of your mattress and pillow when we breathe them in, but they’re not going to be just in the regular air; unless you’ve just vacuumed a room, then they will be in the air for about 15, 20 minutes after you vacuum the space. So you don’t really need to protect yourself with a mask, but it’s interesting that you brought that up because for patients who live alone or don’t have an alternative, I will ask them to wear a mask when they’re vacuuming and then stay out of the space for about 20 minutes. So there must’ve been some thought that it can help reduce some inhalation of those dust mite particles.

Daniel Lobell: (24:15)
The other invisible enemy, dust mites.

Dr. Chhavi Gandhi: (24:18)
The other invisible enemy, there you go. [Laughs].

Daniel Lobell: (24:22)
[Laughs]. So COVID 19, I’ve heard, presents sometimes like an allergy. How do people who suffer from allergies know? What are the ways that they could tell the difference between the two?

Dr. Chhavi Gandhi: (24:34)
I love this question because we get it several times a week in our office. It is very, very hard to tell the difference between COVID-19 and allergies. There’s usually a single feature that would differentiate them. And that’s a fever. The tricky thing is only about 50% of patients with COVID present with fever. So almost all of the symptoms will overlap. You can feel fatigue. You probably don’t get a ton of body aches with allergies. But having suffered from that myself and seeing patients, you can feel extreme fatigue, you can feel like your brain is foggy, you get all these nasal symptoms, you’re congested, you can have a cough, and all of that is regular allergy stuff. I regularly will say to patients, “Let’s take your daily allergy medicine. If you feel better an hour or two after you’ve taken it and you feel back to normal, I’m going to guess it was your allergies, but if you’re not better, then we need to go get a COVID test and there’s really no other way to know.”

Dr. Chhavi Gandhi: (25:30)
And COVID tests aren’t perfect either, but it’s the best thing we’ve got right now. So we are encouraging people to do that. I will say that from the fall of 2020, moving forward with a lot of my pediatric patients who were going back to school, we maximized all their allergy medicines because the start of school overlapped with our very bad ragweed season. And everyone’s noses are a mess at that time and some people have very bad respiratory chest symptoms from their ragweeds. So we definitely amped things up this fall for everyone so that we could very clearly distinguish if they were well controlled with their allergies. If they were then getting another symptom, we would assume it was infectious and they would get it checked out.

Daniel Lobell: (26:10)
Yeah. You know, what’s also coming to mind is an article I read that said that asthma inhalers help fight off COVID-19. Have you seen anything to that effect?

Dr. Chhavi Gandhi: (26:28)
I don’t believe they fight off COVID-19. There are two different, big groupings of asthma inhalers. There are the kind that open up your airways temporarily and then there are the kinds that reduce inflammation. What we do know with our asthmatics who are well controlled and who need to take an inhaler to reduce the inflammation, they tend to do better when their inflammation is reduced. So they won’t get as severe as they normally do with catching any kind of cold or any viral infection, be it COVID-19 or something else. The ones that open you up right away will help you symptomatically feel better, but I don’t believe there’s any kind of validity to it fixing COVID or making it better, other than the fact that it would reduce the severity of an asthma exacerbation in somebody. Now we do have several post-COVID patients who didn’t have asthma before, who now have asthma-like features of disease. And we’re treating them as if they have asthma with the same medicines and that is helping them now. But I don’t think it would have prevented anything in the active phase of the infection.

Daniel Lobell: (27:35)
Wow. That’s interesting. Which one is Albuterol?

Dr. Chhavi Gandhi: (27:38)
That’s the one that opens you up, that’s the bronchodilator. It’s one of the categories of bronchodilator and it opens you up immediately and just gives you relief right away. That is usually the first line treatment for anyone who’s got symptoms. But we don’t want that to be the only thing somebody uses – even though it’s great to use and you always should use it when you need it, if you’re needing it more than twice a week in the daytime without some specific trigger like exercise, it usually indicates that there’s some underlying inflammation in the bronchial tubes, in the airways, that we need to give you the other inhaler for, or we have other treatments that reduce inflammation. But then you would require an anti-inflammatory and those are more long-term treatments, but those are the ones that if you need them, are the most important to be on. And your Albuterol is always your guy that you carry with you that you’ll use anytime you’re having active symptoms and it should relieve you fairly quickly.

Daniel Lobell: (28:41)
Are they putting COVID patients on nebulizers?

Dr. Chhavi Gandhi: (28:45)
In general we’re discouraging people from using nebulizers. I think in the hospitals, a lot of them are also trying not to use nebulizers because a nebulizer is an aerosolizing procedure. So it could in fact take the patient’s COVID virus and nebulize it into the air and expose people in the room. So even for our conventional asthma patients from the spring of last year, I was encouraging them to get off nebulizers and use inhalers instead to protect others in their home environment. And the hospitals were starting to use Albuterol inhalers instead of nebulizers as well, for the same reason.

Daniel Lobell: (29:26)
What about patients who can nebulize at home? Would that be encouraged or discouraged?

Dr. Chhavi Gandhi: (29:31)
Discouraged, unless they’re living alone, because the same thing could happen – it could nebulize, we don’t know everyone’s status and if they happen to have an increase in symptoms and we don’t know it’s COVID related if they were to use it. For instance, if I have a five year old who’s using a nebulizer, and the mom is administering it and patient has COVID, mom is now very exposed to COVID suddenly. Whereas when you’re using an inhaler, there’s a lot less aerosolizing of that virus in the air. So in general, we’re trying to discourage nebulizer use right now and using more of the meter dose inhalers or the dry powdered inhalers instead.

Daniel Lobell: (30:07)
Unless you live at home alone, right?

Dr. Chhavi Gandhi: (30:09)
Alone, right. And frankly I’ve had asthma since I was very little, but I have almost never used a nebulizer, I think with really good technique and good use, an inhaler works just as well as a nebulizer.

Daniel Lobell: (30:21)
I have very mild asthma. I have used a nebulizer and it’s been really helpful to me at some points, when I’ve had flare ups, but yeah, I don’t know.

Dr. Chhavi Gandhi: (30:30)
Yeah. I think it’s a very soothing device when you’re ill and part of it is that it’s got saline in there and the saline acts like a humidifier. And so I will call patients who don’t have it, and tell them that they can take their inhaler and go sit in a steam shower. I feel like the steam really mobilizes some of that mucus out and then you feel better. Again, a lot of patients will say the same thing you did and I encourage them to use the nebulizer then if that’s what makes them feel better during non-COVID time.

Daniel Lobell: (30:57)
One of the only times that it’s like an advantage to live alone.

Dr. Chhavi Gandhi: (31:00)
Yeah, there you go. [Laughs].

Daniel Lobell: (31:00)
[Laughs]. Unless you live alone with a cat.

Dr. Chhavi Gandhi: (31:06)
[Laughs]. Yeah, exactly.

Daniel Lobell: (31:10)
I saw a report that the Pfizer vaccine was causing serious reactions in some people with allergies. Do you have any idea why, and should people with allergies be getting the vaccine right now?

Dr. Chhavi Gandhi: (31:21)
Yeah. So the definition of serious reaction is being looked at more closely. What we would like to see is some markers of maybe a blood draw or a few things being looked at, to see if it was truly an allergic reaction or something else. A lot of people are reporting different types of symptoms, such as “I feel a fullness in my throat and I felt a little dizzy” and of all of these symptoms that people are reporting – I’ve not really heard anybody have anaphylaxis or a true cascade reaction. There have been a couple of cases reported with the Pfizer vaccine that are being looked at more closely to see what was going on. One of the chemicals in there, which is polyethylene glycol, is being looked at as possibly being the implicating factor.

Dr. Chhavi Gandhi: (32:08)
It’s part of the coding of the capsule that is protecting the virus and it is one of the ingredients in it and they’re looking to see if that possibly is the cause. For the majority of patients – and we have formal guidelines from our societies, as well as what I’ve been doing with patients and for myself – patients with allergies absolutely should be encouraged to get the vaccine. I think they should talk to their allergist if they have any questions or concerns. In some cases, we would recommend pre-treating with certain medications before going in to get the vaccine, probably waiting 30 minutes instead of 15 minutes after the vaccine. And if they happen to be somebody who requires epinephrine injectors for other diseases, they should take it with them, and they should take their Albuterol inhaler with them if they normally use it for other things.

Dr. Chhavi Gandhi: (32:56)
There are a select group of patients that are being asked to be looked at more closely for whether or not they should get them. Those are patients who have more severe underlying causes for anaphylaxis, there are patients who make certain chemicals, so histamine gets produced in their body through mass cells. And some people have a disorder where they’re either too abundant with their mass cells or their mass cells are triggering off more frequently than others. They’re more prone to getting anaphylaxis for many different reasons, vaccine related or not. So we’re being a little more cautious with those patients, but it’s a rare condition and it is not something that the general public would have to worry about. We’re encouraging every patient with allergies to contact their allergist and to seek medical attention and advice if they have concerns. But for the majority of allergy patients, they should have no hesitation to get this vaccine.

Daniel Lobell: (33:47)
Forgive my ignorance, anaphylaxis, not a Russian girl.

Dr. Chhavi Gandhi: (33:54)
No! [Laughs]. First with regard to that cascade reaction we were talking about earlier, in patients who have a profound allergic reaction, whether it’s from a food or some exposure, it can start off as something benign, such as a few hives or itchy mouth if they’ve adjusted something, but it can progress to things such as throat closure or fullness, where it starts to swell in the airway and really severe asthma-like symptoms, full body hives. And in the worst case scenario, the blood pressure actually drops and you can go into shock. So all of those symptoms could be lumped into this category of anaphylaxis, and there are ones that are just the skin and then there’s some that are the tummy where you can get nausea, vomiting, diarrhea and then some where it becomes systemic where it’s involving multiple organ systems and, or causing a drop in blood pressure.

Dr. Chhavi Gandhi: (34:43)
The way this works is if you catch it on the early end and by catching it, I mean give medication immediately, which has epinephrine, it can oftentimes just stop it in its tracks right there. Once you get to the point of it being a blood pressure issue or an airway issue, of course we would try epinephrine, call 911, get everything looked at, but the earlier on you get the medication the better, because the cascade becomes exponential and can in those cases be life-threatening. And so we have not seen that with the vaccines and I’m happy to hear it. And we’re seeing the numbers of people who got vaccinated in both of the trials are in order of tens of thousands. There have been a few cases where people had suggested reactions and they should absolutely be looked at so we have more clarity on it. But for the majority of our patients, they should be fine. I was very fortunate to get my vaccine a couple of weeks ago and I have terrible allergies and did just fine and I would encourage anybody to get it. Absolutely.

Daniel Lobell: (35:47)
So have you burned your mask?

Dr. Chhavi Gandhi: (35:52)
No. [Laughs]. We also need to do all of our social distancing, continue to wear a mask, limit large crowding, all of the things we were doing before still need to happen, because we’re still not clear whether or not being vaccinated prevents you from transmitting the virus to somebody else. So if you were to be exposed, you might still carry the virus inside your respiratory tract. You might not get sick and feel symptoms, but you could pass it on to others that are not vaccinated. I think the goal is that once we get to a place of “herd immunity”, where we think things are safe, that the majority of people are not getting illness or not being sick anymore to the levels that we’re seeing right now, that some of those distancing and masking measures would be reduced, but I don’t see that happening anytime soon right now.

Daniel Lobell: (36:43)
Well, they should definitely have parties for people who are all vaccinated. [Laughs].

Dr. Chhavi Gandhi: (36:49)
[Laughs]. I think the goal is to maybe start looking at your own house pod and, and, for us, my parents live just two miles from me and I have been extremely careful. We hadn’t been inside each other’s homes until September when it started getting cold. And then we wore masks and stayed 20 feet apart from each other. And if we were eating, we’d go to separate spaces. And I think what would be lovely is if all the adults were vaccinated, that we could maybe loosen some of that. Now children can still carry it and transmit it. They’re not right now approved to get the vaccine. And so that’s another layer of this whole process that we have to wait for before everybody is safe enough to start having those house parties. [Laughs].

Daniel Lobell: (37:35)
Take that, children. [Laughs].

Dr. Chhavi Gandhi: (37:37)
There you go. [Laughs].

Daniel Lobell: (37:38)
Let’s talk a little bit about the patient-doctor relationship. What do you think are some of the most important facets of that relationship?

Dr. Chhavi Gandhi: (37:53)
I think that building a connection with the patient and having mutual respect for each other which builds trust is probably the backbone of having a good relationship with your patient and also really listening to their stories. When we have new patients in the office, we dedicate a full hour to them. A significant portion of that time is taken for history, where we go into great detail about what their issues are. And if you spend the time and you answer their questions and you educate them and you explain why you’re recommending certain treatments and medications, I think the relationship is just so much fruitful for both the doctor and the patient. I am a big proponent of educating patients. I think an educated patient who understands their disease process is so much more compliant and they end up doing so much better than a patient who is not invested that way. If you take the time to do that, it goes such a long way in your next visit and your next encounter with them, and them having great questions to come back with. I think that is not a luxury everybody has, and I’m very lucky to be able to have the time to spend with patients and do that. It’s one of the reasons I love this field because it does require a lot of sit down and a lot of interaction with the patient.

Daniel Lobell: (39:19)
I imagine there’s a lot of overlap between what you’re doing there and what your dad spent his life doing.

Dr. Chhavi Gandhi: (39:26)
[Laughs]. Yes, there is a lot, and I think that it would be helpful for all of us to get some training in that as well in medical school. I think there is a lot of that and understanding how to approach a patient. There are some patients when you give them the news that they’re allergic to food – there are some mothers and fathers who are brought to tears. There are people when you tell them, “Hey, you know, that dog you have at home is causing all of your child’s problems right now” – it’s a devastating thing to hear. There are a lot of times where that interaction is painful for them, and it’s hard, and recognizing that and understanding that is really important.

Dr. Chhavi Gandhi: (40:05)
I have two children, they happen to have a ton of allergy. I became an allergist before I became a mom, but understanding that, being able to pull from those examples for them too sometimes is really helpful because I have an understanding of how this goes and how stressful it can be and how to implement it on a day-to-day basis. I’ve lived through a lot of it personally and with my kids and I don’t think any of it should be undermined, it’s all important. Whatever’s important to that family, that patient or that adult – it’s important to them. You have to validate that and you have to work with them – if you act like nothing’s a big deal, they’re not going to think you care, right? And then there’s no investment moving forward for them. So I think really getting engaged with them and understanding that their life is being affected by whatever you’re doing is an important part of the relationship. I think a little bit of therapy and psychiatry would be helpful for all of us as physicians. [Laughs].

Daniel Lobell: (41:12)
[Laughs].

Dr. Chhavi Gandhi: (41:12)
I am sure you could say that for the majority of patients who we have to deal with, pediatricians are up there, internal medicine doctors up there, there’s a lot of physicians who have to do this with every patient almost all the time.

Daniel Lobell: (41:23)
Yeah. There definitely needs to be empathy training for some. [Laughs].

Dr. Chhavi Gandhi: (41:29)
[Laughs]. Absolutely.

Daniel Lobell: (41:29)
In a way you’re lucky. It’s a strange thing to say, but in a way, you’re lucky that your kids suffered from allergies because I’m sure that that did wonders for you as a doctor with the amount of empathy and sympathy that you have for your patients as a mother going through that.

Dr. Chhavi Gandhi: (41:47)
Yeah. It started very early for me in motherhood. My daughter was eight weeks old and was reacting very profoundly to my breast milk. And I was in denial about it because I thought, “I’m not going to be one of those moms who thinks everything my kid is going through is a food allergy, because food allergies are just thrown around.” It’s really big diagnosis that is thrown around but a lot of the times, it isn’t there. So it took somebody else to be like, “You should probably get her allergy tested.” And that began my journey with my kids and their allergies. They both have food allergies, they have eczema. One of them has chronic hives. The other one has contact allergies. And I feel like between my household, I’ve got most of the different allergic diseases covered, but I do feel like it was almost the perfect pairing that I could learn from my kids.

Dr. Chhavi Gandhi: (42:36)
I could learn from my career. And then I could learn from my patients. And then the three are really interconnected where we can learn from each other and teach each other. I’m very grateful for the place I have been. And then I tell them, “Trust me, if I think there’s a treatment coming up, I would be the first one to tell you, because I want it for my children. I want it for your children.” And so we’re very intertwined and interdependent on each other that way.

Daniel Lobell: (43:05)
Yeah. You must be so much more invested at this point, just because of that. I feel like I’ve heard the idea that children get to pick who their parents are. Have you ever heard that notion?

Dr. Chhavi Gandhi: (43:15)
Yes.

Daniel Lobell: (43:15)
Yeah, so they probably knew they were going to be allergic. They’re like, “Well, let’s go there.”

Dr. Chhavi Gandhi: (43:21)
That’s a good one. We’ll stay there.

Daniel Lobell: (43:22)
Yeah. Let’s shift a little bit over to technology. You know, we’re talking from the Doctorpedia podcast, which is a tech platform for medicine. How do you feel that technology is changing the health and wellness space? And do you think it’s for the better?

Dr. Chhavi Gandhi: (43:41)
I think there’s a direct overlap and there’s no escaping that this is the direction it’s going. Patients look up things. They do their own “research”. There are select reputable data sources out there. I find that patients who want to look up things will look up things. And I spend quite a bit of time having to clarify patients’ understanding of their diseases or what could be going on based on misinformation that is out there. And there’s so much misinformation out there, especially with vaccines and allergies and food allergies. And so we, as allergists spend a lot of time having to clarify information. I think that having a reputable source is so important. I’m very passionate about education and what Doctorpedia is doing.

Dr. Chhavi Gandhi: (44:33)
What Doctorpedia is doing is so important because I think it provides such a vetted, clear, concise place for patients to go to and find information that could directly help them and then help them in finding the right doctor and getting the individualized personalized care they need. But we do need to take back the misinformation that’s out there; in some respects I think every person should empower themselves with knowledge and I’m all for that. We just need to provide people with a reputable place to go. And I think it’s going to be a great thing to have so many invested physicians working in this, to get patients good and healthy information.

Daniel Lobell: (45:13)
I’ll tell you who I think is behind all the disinformation in the allergy field, you want to know?

Dr. Chhavi Gandhi: (45:21)
Oh, who is it? Who is it?

Daniel Lobell: (45:21)
It’s that diabolical Mr. Peanut.

Dr. Chhavi Gandhi: (45:21)
[Laughs]. Mr. Peanut is doing it. There you go. He feels very slighted these days. I’m sure he’s trying to take something back now.

Daniel Lobell: (45:39)
Yeah. He’s behind the scenes, you know, working fake websites. And are there any apps that you use to monitor your own health or any digital platforms?

Dr. Chhavi Gandhi: (45:52)
Yeah. Now that’s interesting. I mean, I use some apps on my, on my phone to track what I’m using as far as exercise and how much I’m moving and things like that. I am starting to now measure my blood pressure and do things like that. But I have not specifically used one platform. I think that is where things will go, where there’s going to be a really nice interface between what patients are doing at home and my doctors can see at work. I think it would be the next big step is that everybody has like a really good, clear program to use that is vetted out and helpful.

Daniel Lobell: (46:32)
Yeah. I think there’s always all these new things coming up on the market, for instance, I’ve been getting target marketed because I guess Facebook knows that I’m always trying to lose weight for something called lumen. I don’t know if it’s real or if it’s fake, but it says it’s the first device that you can use to hack your metabolism. And it looks like a vape, a cigarette, but you breathe into it and it tells you on your iPhone what you should be eating. Is that nonsense?

Dr. Chhavi Gandhi: (47:15)
Yeah. I don’t know enough about what that app has to say, but I can’t imagine it’s just as simple as that. I mean, as you know, and most people know, weight loss and all of that is such a multifaceted thing. It involves so much about diet, exercise, metabolism, your age, your weight. I mean, if you’ve ever looked at these programs, you can plug in your height, weight, and your age to ask “How fast can I lose weight?” Everything is a part of it, right? How old are you? How much do you move in a day? What’s your race? What’s your gender? And all of these things play a role. I’m curious, but I doubt it’s going to be a fix for all.

Daniel Lobell: (47:53)
I’m looking it up as we speak. It says it uses a CO2 sensor and flow meter to determine the CO2 concentration in a single breath. Is that it?

Dr. Chhavi Gandhi: (48:03)
So that’s implying that CO2 has something to do with your metabolism. I’m guessing. I don’t know, I have not heard that before.

Daniel Lobell: (48:11)
What’s interesting about this is that if it is something that works, I wonder if there’s something like it that could be invented for allergies, where you could have somebody breathe into something and it would analyze something to know what you’re allergic to.

Dr. Chhavi Gandhi: (48:28)
We have an interesting device that we use in our office called a Phenol monitor. It measures nitric oxide in your breath, and that can correlate with allergic asthma and how severe and inflamed you are. It’s an indirect marker, but that’s coming straight out of your bronchial tubes. I think with allergy in general, because it has so much to do with what’s circulating in your bloodstream and your antibodies, that’s going to be an interesting method, but I’m sure that there are some very smart people who can come up with some things that would make it a good application for some patients.

Daniel Lobell: (49:06)
That’s interesting. So, going back to Doctorpedia, what involvement do you have with Doctorpedia and what can we look for on the site?

Dr. Chhavi Gandhi: (49:17)
So I am going to be one of the chief medical officers for the allergy immunology channel. We’re building it from the ground up, so I’m hoping to include content on very common allergy conditions, as well as some of the more interesting things that people might not have heard of, as well as things to do with the immune system. And there’s so much talk about innovations and vaccines and all of that. We’re hoping to have content that spans our field, which is very broad. And the goal is to make it friendly for patients on the day to day problems, as well as some people who might have more rare, complex problems and I’m very excited to get things moving forward.

Daniel Lobell: (50:06)
I’m excited to see what you’re going to be doing on there. And I think a lot of people will be. It’s been an absolute pleasure having you on the podcast today. We’ve covered so much, there is a lot to reflect on, perhaps we could say.

Dr. Chhavi Gandhi: (50:19)
Yes, thank you. [Laughs].

Daniel Lobell: (50:21)
[Laughs].

Dr. Chhavi Gandhi: (50:21)
That was a good route for them. That was good talking to you today,

Daniel Lobell: (50:29)
Dr. Gandhi, I ask every doctor this question to round off the interview and you’re no exception. You’re getting the question too. What do you do to stay healthy?

Dr. Chhavi Gandhi: (50:40)
So what do I to stay healthy? I eat very healthy, vegetarian, but I also have a pretty balanced diet. I exercise three times a week. I meditate every morning. I work constantly on being more mindful because I think that really plays a big role in how I deal with stress. I think it’s sometimes overlooked as a really big component of health. And I think trying to stay in the moment and being happy has a lot to do with it. I think every year I’m learning more and more about how to stay healthy as I’m getting older and I look forward to continuing to learn on this journey.

Daniel Lobell: (51:19)
Follow up question: When you talk about mindfulness, is there something specific you can give the listeners a tip on?

Dr. Chhavi Gandhi: (51:26)
Yeah, I think, for me, when I feel like I’m in a stressful moment or there’s a lot happening, it’s very easy for me to get really caught up in the moment and be really upset. And I’ve started trying to just notice myself doing things. So I’ll say like, “Oh, okay. I seem like I’m getting stressed or, okay, that sounds like I’m getting angry.” I can notice it and recognize it, let the emotion flow through me. And then I feel like I can recover from it much faster. There are no real bad emotions that exist. I think we just have to learn how to not completely succumb to it. And so by being more mindful, I will come back to the present moment and see what’s going on. Especially during this COVID time, our lives have changed so much. I’ve spent so much more time with my family. Good and bad things come out of that. And I think for me trying to recognize that this is a rare opportunity to spend this much time with my children who are normally in school all day, trying to soak it in as much as I can and I think this really can change your outlook on what’s happening for you.

Daniel Lobell: (52:33)
Yeah. That’s a great piece of advice. It reminds me of something I heard when I was about to become a father and I was freaking out and I heard somebody say, “Just make it all fun for yourself. Like don’t stress about it. Just everything that you’re worried about, look at it as like, “Oh, I can’t wait to have fun changing a diaper or I can’t wait to have fun.” It changed my perspective so much. And it was just a wonderful little piece of advice that I credit so much of my current happiness to.

Dr. Chhavi Gandhi: (53:08)
Yeah, I think that’s true. I think if you can just notice it and let it happen and be playful with it and just think, “That’s a human emotion I’m having” and people have bad days and people have good days, but I think if you can notice it for what it is – it just makes things lighter. Like you said, you’re just going to enjoy those moments more.

Daniel Lobell: (53:37)
Enjoy the ride, in other words.

Dr. Chhavi Gandhi: (53:37)
Enjoy the ride. Absolutely. And hopefully we’ll all get out on the other side of this pandemic better for it.

Daniel Lobell: (53:37)
Enjoy the ride and watch out for Mr. Peanut.

Dr. Chhavi Gandhi: (53:41)
[Laughs]. I will do. Absolutely. Thank you so much.

Daniel Lobell: (53:48)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

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