Sleep Well and Live Well | Episode 32
Sick of the fatigue and fog? Fed up with the unpredictable flares? Hangry from the super restrictive diets?
Hello and welcome to the Crunchy Allergist Podcast.
A podcast empowering those who, like me, appreciate both a naturally minded and scientifically grounded approach to health and healing.
Hi, I'm your host, Dr. Kara Wada. Quadruple Board Certified Pediatric and adult allergy immunology and lifestyle medicine physician, Sjogren's patient, and life coach.
My recipe for success combines anti-inflammatory lifestyle, trusting therapeutic relationships, modern medicine, and mindset to harness our body's ability to heal.
Now, although I might be a physician, I'm not your physician and this podcast is for educational purposes only.
Kara Wada, MD: welcome everyone. Thank you for joining us again, or welcome if you're new to the Crunchy Allergist Podcast, where we talk all things allergy auto immunity and anti-inflammatory living.
One of the real big pillars of anti-inflammatory living is making sure that our bodies have ample time and space and energy to recharge our batteries.
The main way we do that is through the gift of sleep.
I am so excited and honored to welcome Dr. Bhopal today, who is a board certified psychiatrist, sleep medicine, and integrative holistic medicine physician.
She is the founder of Pacific Integrative Psychiatry.
Serving patients across California, and she brings various disciplines into her practice to really offer a comprehensive approach to mental health, including nutrition, mindset, coaching, psychotherapy, yoga, meditation, and Ayurveda.
She has a YouTube channel for clinicians where she shares holistic strategies to optimize sleep and mental health.
I was just so absolutely impressed by Dr. Bhopal's talk at the Aila Autoimmune Warrior Conference, which is how we connected and through some mutual friends.
I'm so excited and thankful that you were able to take time out to join us on the podcast today. Welcome.
Nishi Bhopal, MD: Thank you so much for having me.
I'm really grateful to be here today.
Kara Wada, MD: Can you share a little bit? How did you end up doing what you're doing?
Nishi Bhopal, MD: Yeah, it's been a bit of a journey . As it has been for many of us who do like integrative medicine and bring those elements into our practice.
Like many of us who do practice these modalities, a lot of this came from personal experience.
Like my interest in integrative medicine Ayurveda, yoga meditation.
It was for selfish reasons in a way to learn how to better manage my own system.
Just to backtrack a little bit, I started out doing internal medicine as my residency.
So after medical school I matched into internal medicine.
I was extremely burned out. I was anxious, I was exhausted, sleep deprived.
Which is not an unusual story for those of us who, go into medicine.
Yeah. But I was just not doing well during my intern year, and so I took a step back to reflect on what I really wanted to be doing.
One realization I had was that I was in the wrong specialty and that was contributing to some of my burnout.
I'd always been interested in psychiatry, but I didn't actually really think about pursuing it as a career or as a residency.
But I took some time just to step back and realized that was actually a better fit for me.
After my intern year, I switched into psychiatry and I've always been kind of a sleepier person than my peers.
I always needed a little bit more sleep than the people around me.
Yeah. Really struggled with the irregular sleep schedules that we had in residency.
It took a huge toll on me and I felt like it took a larger toll on me than maybe some of my co-residents.
That may have just been my perception, but that's how I felt.
So I got really interested in sleep and the circadian rhythm, and also how to help my patients because in psychiatry clinic we see so many sleep issues, right?
It's like sleep and mental health go hand in hand.
Kara Wada, MD: But my understanding is there are not many people that have your combination of training from talking.
I, there, there happened to be, so take us back maybe five, six years ago, seven years ago now are as a first year attending slash education fellow, our non-clinical workspace was shared with our sleep medicine fellows.
And so one of the sleep medicine fellows that year happened to also be psychiatry trained.
And so for those who are listening who maybe aren't in the medical field, and please correct me if I'm wrong, like you can enter sleep medicine fellowship from many different arenas.
Many times, or maybe more often, it will tend to be someone who has a pulmonary background or maybe has a neurology background, psychiatry as well.
And then I even know someone who was a cardiologist who did sleep training as well. But that combination between psychiatry and sleep is so helpful, but there's just not that many of you.
Nishi Bhopal, MD: That's very true.
You certainly can enter into sleep fellowship after a variety of different specialties.
So in my fellowship, there was just three of us in our program and there was me, the psychiatrist, my other co-fellow was a neurologist, and our third co-fellow was a pulmonologist. That was really great.
This was why sleep medicine is so interesting because it truly is multidisciplinary and we can all bring something different to the table and there truly aren't a lot of sleep psychiatrist out there.
Even within the field of medicine it's really, sleep medicine is really misunderstood.
Even some of my MD colleagues, like I'm also an MD.
They tell me you can't do sleep medicine as a psychiatrist.
That's only for pulmonary or that's only for neurology.
Even within our profession, there are misunderstanding about who and who cannot practice sleep medicine.
So sleep medicine can also be practiced by pediatricians.
So we did pediatric clinic. Yeah. Yeah. So yeah.
Kara Wada, MD: Dr. Brown on a few weeks ago, and she's a pediatric pulmonologist, so That's great. Yeah.
Nishi Bhopal, MD: Yeah.
There was a pediatric psychiatrist doing sleep in one of our adjacent programs. Yeah.
So it truly is multidisciplinary because sleep involves breath.
It involves the brain and it involves mental health.
Kara Wada, MD: Yes.
And increasingly understanding how it interacts with our immune system too.
We had our our first book club last night with author Donna Jackson-Nakazawa, and she really is very fascinated in this intersection between our brain and our nervous system, our moods, and our immune system.
All that interplay comes into play as a psychiatrist sleep medicine expert.
Do you have particular tools in your tool belt that you rely on to help folks out in your practice?
Nishi Bhopal, MD: I do.
*The first step that I recommend*, whether you are struggling with sleep yourself or if you're a clinician working with patients who are struggling with sleep, *is to really assess what's going on.*
Because what I see a lot of the time is that when people have trouble sleeping, it gets put into this bucket of insomnia, right?
And then we start reaching for solutions before really understanding what the underlying cause might be.
And so then it's almost like you're putting a bandaid on the problem without really getting to the root cause, and then you may even become reliant on those solutions.
And then you can't sleep without those things because you never actually addressed the driving force behind the sleep issue.
Kara Wada, MD: I uncover this far too often.
So it's interesting as allergists, we actually, the sounds may be counterintuitive, but we hate Benadryl.
We really do prefer the less sedating antihistamines because overall they're safer, but many times I'll have patients who will double dip and get, that extra drying from from the first generations like Benadryl and the sedation to help them sleep.
But that really can lead to some kind of maladaptive like strategies and behaviors and some really dry out your system too.
Nishi Bhopal, MD: That's exactly right.
I'm not a fan of Benadryl either, and and like I see patients all the time who are taking Benadryl or these sedating antihistamines to help them sleep.
And these kinds of things may have a short term benefit, right?
If someone is dealing with a flare up of an allergy or something, and they do well with Benadryl, that might be okay for a couple of days but not for weeks on end.
I had a family member who reached out to me a few weeks ago about something else, but then they mentioned that, Oh, I've been taking Benadryl from sleep and I watched your YouTube videos and I learned that maybe that's not good.
And they've been taking Benadryl for years and noticing that they were having memory issues and cognitive issues, and this person was a little bit older as well.
And so we had a long discussion about the proper use of Benadryl, how to address the sleep better, but also the cognitive and mental health and memory impacts of it.
Because a lot of people don't realize how it can really affect your cognition.
Kara Wada, MD: Yeah. And it's not just, it's not uncommon that I'll have people say, Oh, I wake up feeling hungover.
I don't like that sensation.
But there really are studies that now show that long term can impact our memory.
Which is I think a scary proposition, especially for any of us who maybe have family members, parents, grandparents who have struggled with dementia or other memory conditions.
As you are thinking about that patient and digging into some of those root causes, are there some kind of recurrent themes or things that will come up kind of time and time again?
Nishi Bhopal, MD: Definitely. So there's a few different aspects that I'd like to look at.
So the first thing is always, how are they breathing during their sleep because sleep apnea is incredibly common.
So sleep apnea is a condition where people stop breathing during their sleep.
It really is a breathing disorder, even though it's classified as a sleep disorder.
It fundamentally is a breathing disorder that happens during sleep and it's often missed.
You may have heard me say this in my talk Aila Health, that it can show up in a very subtle way in women.
It is incredibly underdiagnosed in women, and I've seen patients in my practice where they may be struggled with insomnia for years, or they had this kind of chronic fatigue, depression sort of picture.
They may have even been diagnosed with fibromyalgia or dysthymia, which is a persistent depressive disorder when actually it was sleep apnea that was largely contributing to how they were feeling.
So that's the first thing that I like to allow.
Some of the symptoms of that may include snoring, but again, in women it might not show up as that loud snoring.
When we think of sleep apnea as happening in like the overweight male with a thick neck.
It can happen in young, petite, thin people.
Sometimes waking up un refreshed, feeling sleepy all the time, waking up with a dry mouth or a sore throat.
Headaches especially morning headaches could be a little bit of a clue. Bruxism or grinding of the teeth or clenching of the jaw can be another clue.
And then waking up throughout the night is another sign.
So if people are experiencing that, I would typically send them for a sleep study which is a, pretty straightforward process.
It's a little bit involved, but it can give us a lot of data and that's often the first thing that I would do if I suspect that there's some kind of gritting issue going on
Kara Wada, MD: That, I think is really important for us to think about and to consider.
I just wanna reiterate because I think that's powerful statement that things that really can be diagnosed as fibromyalgia or pain or depression really can be, you know, the root cause can be impaired sleep and your body essentially not getting enough oxygen while we're sleeping, which is what can happen with the sleep apnea.
I know longer term, talking at home when my husband and I actually get to have a conversation, an adult conversation, and not get interrupted every 60 seconds.
But he's a cardiologist and he sees some of the downstream effects that untreated sleep apnea can have, which is essentially to increase blood pressures on the right side of the heart which also can lay silent for a long time.
Nishi Bhopal, MD: That's exactly right. Yeah.
There's so many downstream effects and certainly there's cardiovascular effects as you mentioned.
Increased blood pressure, increased risk of stroke, increased risk of cardiac arrhythmias or irregular heartbeat.
Then on the psychiatry or mental health side, we see an increased risk of depression.
We can see anxiety or even ADHD like symptoms.
Like I'll see that in adults and like I don't see kids anymore, but we did an, like when I was doing my sleep training, we would do pediatric clinic and so we would see kids who had hyperactivity and may have been diagnosed with ADHD and put on stimulants when actually there was a sleep disordered breathing issue happening behind the scenes.
So it can really affect everything,
Kara Wada, MD: Adenoids, any of those things. Yeah. That's great.
Yeah. So one thing that's evolved after I completed my general training and need to do a little CME on, so I'm gonna pick your brain now.
Where do I've heard about these at home sleep studies, are those, it seems like that might be like a less expensive modality, where do those fit in?
Or is that an option for some people?
Nishi Bhopal, MD: Definitely home sleep studies can be really helpful because they're more convenient.
You're sleeping in your own bed, you're not hooked up to a bunch of wires.
So it's just a lot more comfortable and convenient for folks.
Now a lot of this is insurance driven as well, so now many insurance companies do require that somebody does a home sleep test before they do an in lab sleep.
Okay. So a home sleep test can be helpful to rule out sleep apnea or sleep disordered breathing to see if there are oxygen dips during the night.
See if there are any pauses in breathing, but they're not fully comprehensive.
So if we suspect a different kind of sleep disorder, that's not sleep apnea, for example, narcolepsy or periodic limb movement disorder or a REM behavior disorder.
These are just different kinds of sleep disorders that are not necessarily breathing related.
Those you can't really assess using a home study.
So in some cases we might end up doing a lab study to evaluate those other types of issues.
Or if someone does a home sleep test, but it's negative, meaning it doesn't show that they have any sleep disordered breathing, but they're having a lot of symptoms, then we might actually send them for an in lab study, which is just a lot more sensitive.
Kara Wada, MD: So if someone goes to see their sleep medicine doctor, they may potentially have kind of an at home study first as the first pass.
But to understand that may not be the end all be y'all, is proceeding through that evaluation.
Nishi Bhopal, MD: Think that's really exactly.
Kara Wada, MD: You need to kinda at least give.
I always like to give some anticipatory guidance, when I refer patients to the sleep medicine team to say, Hey, this may be an option. I don't know. I'm gonna rely on their expertise but this is my understanding of how things may go.
Nishi Bhopal, MD: I think that's really important to give people an idea of what to expect because and I share this with my patients as well, and I'll actually send patients to sleep clinic.
My practice is psychiatry.
So I don't have a sleep lab or anything like that.
So I'll send my patients to sleep clinic for evaluation and kind of coordinate with the doctors at the sleep clinic for their treatment.
And so what I tell people is that it might involve multiple studies.
Because sometimes my patients will think " Oh, I'll just get a sleep study done and then I'll be finished and I'll get on treatment. Easy peasy."
But actually it might take a few tries.
So you might do a home study, then you might be referred for an in lab study.
Then you might have another study to test the treatment if you're put on CPAP or if you're doing an oral appliance to make sure it's effective.
So it could be a whole series of things.
It takes time for the interpretation to happen.
So once you do your sleep study, it could take a couple weeks to get the results cuz it has to be scored and then interpreted by the physician and so this whole process could take months.
So that's just one thing I tell people is, this is gonna be a slow moving ship.
It's not gonna happen right away, but just understand what to expect and be patient as we go through this process. Yeah.
Kara Wada, MD: It comes back to that old story of, the tortoise and the hare, that sometimes it is better just to plot along rather than to rush through things.
Nishi Bhopal, MD: That's right.
Kara Wada, MD: One other thing that I have seen trending on TikTok and Instagram and all these different places, the mouth tape.
I'm curious if you have any takes or thoughts or.
Nishi Bhopal, MD: Yeah. Yeah It's one of those things, Yeah, I know.
I've seen it on TikTok.
People ask me about it all the time, and we don't have a lot of data on the benefits of mouth taping.
Like there, aren't a lot of studies on this.
From a clinical perspective, should we really be recommending this to our patients? We're not really sure.
There are potentially some dangers in risks.
So if you do have untreated or undiagnosed sleep apnea, as we're just discussing, that's a breathing disorder.
And if you're taping your mouth and you're not breathing properly that could actually be quite risky and dangerous.
So I recommend people to just make sure they don't have some sort of sleep disordered breathing issue to make sure they don't have nasal congestion.
You're an allergist.
You could speak to that.
Kara Wada, MD: Oh, I that's been the big thing and I mean I've periodically and I haven't as much lately, maybe cuz I wasn't thinking about it as much, but recommended the breathe right strips.
There's some like a few small studies that would say for some people that might be helpful.
Pretty minimal risk as long as you're not allergic to adhesive with those, cuz those at least just go over the bridge of your nose, but...
Nishi Bhopal, MD: Exactly. And I think breathe right strips are great and the other thing with mouth taping too is that essentially what you're doing is you're training yourself to nose breathe rather than mouth breathe.
And there's a lot of benefits to breathing through the nose versus breathing through the mouth.
Just in terms of cleansing the air that's going through your system.
There's so many benefits and we probably wouldn't even have time to go into all of that.
Kara Wada, MD: But maybe a second episode in a few months...
Nishi Bhopal, MD: Right, yeah, for sure. That would be great.
But you can train yourself to do this during the day as well.
Just to be really mindful of how you go through the day how you breathe, slowing down your breathing, focusing on nose breathing, and just really bringing that mindful breathing practice into your daily routine.
Which will not only a benefit for your respiratory system and training yourself to nose breathe, but also for your nervous system and just calming your system through the day. Yeah.
Kara Wada, MD: The short story that I tell folks in the office all the time is our nose and our sinuses, the turbinates, which are the bony structures inside of our nose that are covered in mucosa or tissue that is that makes mucus as the name would imply.
Essentially the purpose is to condition that air before it gets to our delicate lung tissue.
And so to filter out particulate and to warm it up and to humidify it and do all these things.
As you said, there is a lot of physiologic benefit to doing that in addition to some of the downsides with mouth breathing that we see, for instance, with Sjogren, the dry mouth issues like dental issues, sore throat, all those sorts of things.
If you are having congestion, I guess that's my plug to go see your local board certified allergist and or your nose and throat doc so that we can help you out in conjunction with your sleep doc and get everything all together.
That's one of my colleagues at at Ohio State, he is one of the national leaders with Inspire, there's some new devices that are out there that are helpful in sleep medicine and so I guess I say that just to say that there's so much like out there that if you're not getting a good night's sleep, let's use the resources that are out there.
Nishi Bhopal, MD: Yeah definitely. There's so much that people can do and this is where integrative sleep medicine is really exciting as well because we've been talking a lot about sleep apnea.
But there's lots of other, aspects of sleep really in terms of lifestyle, in terms of like mindset and our relationship with sleep.
There's lots of other things to work on and I'm biased because I am a sleep specialist and I'm a psychiatrist.
So for anyone who is struggling with sleep, don't wait.
Like you said, go and talk to somebody.
Even if you wanna start by talking to your allergist or an ENT doctor and then get referred to psychiatrist or sleep medicine is all interconnected.
Kara Wada, MD: My understanding with one of the mainstay of helping folks within insomnia and sleep issues too, is that there's really good science to support things like cognitive behavioral therapy in the treatment of sleep disorders, right in your wheelhouse.
If you wouldn't mind sharing a little bit more about how that works and...
Nishi Bhopal, MD: Cognitive behavioral therapy for insomnia is the first line treatment for insomnia, which means it's the first thing to try for anyone who's been struggling with chronic insomnia which is defined as difficulty staying asleep or falling asleep for three days a week for at least three months.
So there are treatments for anyone listening.
I know when you're struggling with insomnia, it can be really debilitating and it can be really anxiety provoking and really distressing.
But the good news is that there are lots of great treatments that actually work and C B T I or cognitive behavioral insomnia is one of them that a lot of people don't actually know about and there's a lot of misconceptions about it.
So it's actually recommended by the NIH consensus.
So the National Institute of Health and the American Academy of Sleep Medicine, the A S M as the first line gold standard treatment for insomnia.
And essentially what it is, it's a series of therapy sessions.
Usually it's eight to 12 sessions, maybe a little bit more going through various aspects of sleep and the nervous system and our relationship with sleep.
It's more than just sleep hygiene.
So like when I recommend C B T I to my patients, they'll say already tried that.
I turn the lights off. I don't drink caffeine before bed.
And all of those types of things are helpful.
But C B T I goes beyond this and it helps us learn how to relax the nervous system.
It gives very specific protocols on what to do when you can't sleep.
Part of it involves sleep restriction.
There's a lot of relaxation training, there's a lot of mindset reframing.
There's that coaching element, which I know both of us are interested in as well.
Yeah. So C B T I can be done one on one with a therapist.
You need to find a therapist who's specifically trained in this modality because it's different than just C B T.
So you need someone who is specifically trained in C B T I and you can do it one on one, you can do it in a group setting, which actually can be really fun and validating for people.
So a lot of hospitals or therapy practices will offer like a C B T I series.
You can also do it with an app and there's lots of really great apps out there that are incredibly effective.
So you don't even have to leave your home to do it or do it one on one.
There's actually these like new apps that can guide you through C B T I using AI plus live coaching component as.
Kara Wada, MD: Oh, super cool.
I have been really having fun getting into some of health tech like with some collaboration with Aila and at an Aura ring recently just playing around.
Oh, fun. I do wonder and my sleep score the other day was I think an 80 and it was a terrible night of sleep.
And I said, I think that they inflate grades a little bit on .
Yeah. I'm like, that definitely did not feel like a C level night of sleep with how my My son was sleeping and it was up at two in the morning for a fussy baby.
And I just had to laugh that I'm like, Oh, I must actually really need to go for that A plus like I did in, you know, always going for in school.
I've been trying to be better with B plus work in general in life, but I'm like, I guess on this, I'm gonna have to go back to grade inflation.
Are there any particular apps that you tend to recommend to your clients or patients?
Nishi Bhopal, MD: Definitely, yeah I have an aura ring as well, and yeah, I can relate to that.
And if you're like a high achiever perfectionist, then yeah, you want that perfect sleep score every night, right?
And it just doesn't happen.
So I just wanted to comment on that because these apps like the Aura Ring, Fitbit, Apple Watch, that track sleep, like the sleep trackers, they can be really helpful just to give us a little bit of guidance on how we can maybe improve our sleep related habits.
They can give us some insights into how we're doing in terms of like our heart rate variability and our stress levels and areas to improve.
And that's why I love my aura ring cuz it gives me all of that.
But we have to take that data with a grain of salt because like you said, it might say one thing, but you feel very differently.
And at the end of the day how you feel is the most important and it's okay to take a B grade or a C grade on your sleep from time to time.
It's not gonna be perfect every night.
For people who are struggling with insomnia or just poor quality sleep that anxiety can start to creep in when they have a bad night because we're putting a lot of pressure on our sleep quality. And having that expectation that it's gonna be great all the time, it just isn't. It's normal for sleep to fluctuate.
So this is where C B T I can be really helpful to also set expectations.
What your sleep is going to be like on a night to night basis, cuz it is gonna vary.
So some of the apps, to get to your question, so some of the apps that I like to recommend, so one is called Sleepio and it's a C B T I based app.
It's actually based in the UK and the NHS, like the National Health System over there has actually recommended it to population, the general population in the United Kingdom for sleep.
So it's called Sleepio.
There's another one called Som Wrist, which is S-O-M-R-Y-S-T, and that's a prescription app.
So for healthcare practitioners, you can actually prescribe that to your patients for C B T I.
Then there's also a free one that I recommend a lot to my patients.
It's called Insomnia Coach, and there's its counterpart called C B T I Coach. And these are both free apps developed by the va to help people asleep.
So if someone just wants to get a taste of what C B T I might be like, but they're not ready to invest in a paid app or to go see somebody yet.
Those are two great free resources to get started.
Kara Wada, MD: Fantastic. I think one of the things that I hear also a lot in clinic, reminds me just to remind everyone that our sleep changes over the course of our lives span too.
I see it more easily with my kids.
With the nap schedules changing and bedtime's changing as they get older.
But as we are adults and get into older adulthood towards retirement age, our sleep changes as well.
So we may not ever sleep as well, quote and quote, as we did maybe when we were teens.
But that doesn't mean that's abnormal.
To add to what you were saying and.
That expectation, I think for many is that it should be.
Nishi Bhopal, MD: It definitely does fluctuate and even in myself.
I used to be a night owl, like I used to be able to stay up till lilly hours in the morning and then sleep till midday.
And I experience that for a long time.
Like often we think of that in just teenagers or young adults, but I experience that, in even into my thirties.
But now as I've been getting older, my sleep has shifted a lot where I'm, now on an earlier schedule, I maybe don't sleep as long.
As I used to and that's okay, right?
Like I hear this from my patients.
They'll be distressed. I used to be able to sleep 10 hours straight, uninterrupted.
That's normal if you're in your twenties.
But as you get into your thirties, forties, and beyond, sleep is going to change.
And so it's really important for people to have realistic expectations about what is going to happen with sleep as they go through life.
Like as they age, but also as they go through different stages of life.
If you're working shifts or if you're going through pregnancy or if you're going through grief and trauma and loss, all of that's gonna affect your sleep in different ways.
And so if you can understand how it's gonna change and then how to just navigate those times, it can alleviate a lot of the stress that comes with those sleep changes.
Kara Wada, MD: Yeah. That's so powerful. As you think about all things considered, do you have any parting like wisdom or something that you would like to end our conversation on?
To share with the Crunchy Allergist community?
Nishi Bhopal, MD: Definitely. I think one of the big takeaways that I'm also getting from our chat today is not to wait.
So if you are struggling with sleep or mental health or breathing go and talk to somebody. Help is available and there are a lot more therapies and modalities and treatments out there, than you might be aware of.
So don't wait, go and talk to a specialist and every one of us has to sleep and every single one of us has to take care of our mental health.
Mental health and sleep go hand in hand and it affects every single person.
Whether you wanna use an app or talk to somebody one on one, or go online and do some research advocate for yourself and don't wait to take care of yourself.
Kara Wada, MD: Yeah, I think that's so powerful.
One of the very first things that people can do, the first action they can take is they can click over to your YouTube channel, which is IntraBalance or go follow you on Instagram @intrabalance or @pacificintegrativepsych. Or if you're LinkedIn inclined at Nishi Bhopal.
And we will have all of those links and ways to connect on the show notes.
Thank you so much Dr. Bhopal.
I really appreciate it.
The one other place you can check out Dr. Bhopal's talk from the Autoimmune Warrior Conference is the free Aila Health app, which you can track your sleep along with other metrics too.
It was a phenomenal talk that went into even more tips and techniques and things to optimize your sleep. It so helpful. I've sent many patients to go watch it.
So thank you so much.
I really appreciate your time and your expertise and I hope we get to connect again soon.
Nishi Bhopal, MD: Thank you for having me. This was so much fun.
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