This limited podcast series is brought to you by APA's Women Psychiatrists Caucus and hosted by Anjali Gupta, MD, President of APA's Women Psychiatrists Caucus. Dr.Gupta is an Assistant Professor in the Department of Psychiatry at the Georgetown University School of Medicine. She has led a number of wellness and equity initiatives at Georgetown and was selected to be a Gender+Justice Initiative Faculty Fellow for her research on The Experiences of Women in Medicine. She is active with APA's Committee on Women's Mental Health and is Chair of the AMWA Literary Committee. In this series, Dr. Gupta will interview women psychiatrists across the country who lead in a variety of ways. These conversations will uncover insights from guests' journeys in psychiatry on a range of topics, including work-life integration, mentorship, gender equity, and more.

In this episode, Dr. Gupta is joined by Dr. Gia Merlo. Dr. Merlo is a clinical professor of psychiatry at the NYU Grossman School of Medicine and a fellow of the American College of Lifestyle Medicine. She has published four academic books, including Lifestyle Psychiatry: Through the Lens of Behavioral Medicine. She is the founding chair of the APA's Lifestyle Psychiatry Caucus.

Transcript for Audio

Dr. Gia Merlo (00:00): I think that the biggest lesson is you are enough. You are enough, we are good enough. The Winnicottian sort of idea, the good enough mother, the good enough human, the good enough woman and not be so hard on what you're doing and not doing.

Dr. Anjali Gupta (00:21): Welcome to the Women In Psychiatry Podcast by the APA's Women Psychiatrist Caucus. I'm Dr. Anjali Gupta, president of the Women Psychiatrist Caucus, and I will be interviewing women psychiatrists across the country who lead in a variety of ways so that we can hear their stories and learn from their insights.

(00:43): Thank you for joining us today. I'm excited to be here today with Dr. Gia Merlo. Welcome, Gia.

Dr. Gia Merlo (00:50): Thank you. Thank you, Anjali. Thank you so much for having me. This is a lot of fun, I'm excited to see what you're going to come up with and what we're going to talk about.

Dr. Anjali Gupta (00:59): Well, great. How about we start with just how did you get interested in going to medical school?

Dr. Gia Merlo (01:06): Oh, great question. You start with a bang right, Anjali? This is probably the most complex question you could ask me. I actually did not really make that decision. I was straight out of high school, I was doing academically really well, growing up in Baton Rouge, Louisiana. My parents both really had no clue about medicine, no physicians in either side of my parent's family. They said, "You know what, there's this opportunity to go to India and become a doctor in six years." They were like, "Done." I'm like, "Okay."

(01:42): I went to medical school in India. I had an idea of what I was getting myself into, I really didn't. Then, transitioned back to the US as an international medical graduate and pretty much spent a major part of my career since then helping other who may not have known what they were doing and how medicine was going to change them and inform their future. But also, making sure that they had the right fit for medicine and helping them decide.

(02:14): I think the cool thing about medicine is, even though we're all physicians or healthcare providers, we can differentiate and find the niche that works for us. I went into medical school thinking I was going to be a surgeon, and I had an aptitude for surgery, and then I had my child. Guess what? Surgery was out of question in my head, because this was back in the 1980s where I felt like I didn't have as many opportunities so I chose psychiatry, which ended up being a perfect fit for me.

Dr. Anjali Gupta (02:44): Yeah, it's so interesting. So many times, our experiences drive where we are today. When did you decide you wanted to go into psychiatry? Did you actually go into surgery first and then switch, or did you know somewhere in medical school? How did that work?

Dr. Gia Merlo (03:04): Gee, great question. I think it was an interesting accumulation of a lot of things. My daughter was born and I realized that I was not going to have any template of how to raise her as a single mom, because my marriage was falling apart at that time. There were no physicians on either side of my parent's family, but there were also no divorces. I needed to figure out how to raise her that way and I knew that she would have no contact with her biological father because of his multiple issues. I decided, "Okay, how am I going to learn this?" Being at the core, somebody that wants to learn it from the ground up, I said, "Let me become a psychiatrist. At least I'll have some knowledge in how to help developmentally her." Then also, I went into child and adolescent psychiatry, because then it even informed it further.

(04:05): It took me almost 10 to 20 years later, Anjali, before I said, "Oh, wait a second. I need to take care of myself, too." Initially, the impetus was to learn how to raise my child, and through that, I fell in love with helping people. But then, ultimately down the road, I said, "Oh, wait a second. Physician, heal thyself as well."

Dr. Anjali Gupta (04:27): Yeah. I appreciate you sharing that with us. It sounds like you were balancing quite a bit in those early years. How was that? I know work life integration is such an important topic for women physicians. How were you able to balance that? Being a mother to your daughter, and then also take on this career.

Dr. Gia Merlo (04:56): Interesting question. I don't know if I did it well, I think I probably made more mistakes than the average person. I think part of it is that I didn't understand that I could ask for help. I think I was one of those people that thought that I had to do it on my own. Throughout elementary and high school, I always got straight As. It was just one of those things where I thought I had to be perfect. I didn't get the concept of asking for help. I think honestly, back then in the 1980s, I don't think that if we asked for help, people would have understood it as well.

(05:33): I know that when I took my first job at the Children's Hospital of Philadelphia, I was faculty of the University of Pennsylvania, I had a child that was nine, 10 years old. I took on the responsibilities of three psychiatrists before me. I didn't think to say, "Wait a second, I need to take a day off." I had laryngitis one day, I showed up to work. My daughter was sick, then thankfully they had a daycare for sick babies that I could take her to the daycare and come to work. I don't think in my residency, I took a single sick day. It didn't occur to me. What I ended up doing is bottling up all those needs, and then just needing to just really take a deep breath once my daughter was older. I don't recommend that to anybody, and I think that this generation has done a much better job of saying that this is part of what I need.

(06:30): In fact, my first book that I wrote is called The Principles of Medical Professionalism, it's based on a course that I taught for undergraduate standards that were pre-med. The whole concept is we talk about medical professionalism as a profession, but I took that to the next level and integrated wellness into the constructs of medical professionalism. That, to me, is really pivotal because if we don't take that oxygen and take care of ourselves before we put it to others, we are really doing a disservice to our patients and to ourselves because we will burn out. We will be at a place where we're not functioning optimally.

Dr. Anjali Gupta (07:11): I love that. I really love this concept. We hear so much about physician wellness, and people saying that it's super important. Again, not only the individual factors that go into that, but organizational factors that go into it. But I love the concept that really, it is a part of professionalism. That learning how to care for yourself amidst everything else we learn in medical school and residency, and as a attendings, that that's a principal component. I love that.

Dr. Gia Merlo (07:50): I think, to just take that conversation a little further, I think that I don't really like when we teach it separately, either one of them. When we try to teach wellness in undergraduate and graduate medical education, and to physicians, I think it loses its meaning because then that conversation, "Well, we also have to take care of the patient." It's just half of the equation. Then when we're teaching medical professionalism, then there's always, "Well, we've got to take care of ourselves."

(08:22): That balance, we need to merge those two constructs together. Every undergraduate and graduate medical education program in the country requires us to teach medical professionalism. I think if we put the wellness and wellbeing in with that, then I think we've got something that's solid.

Dr. Anjali Gupta (08:39): Yeah.

Dr. Gia Merlo (08:39): Rock solid.

Dr. Anjali Gupta (08:40): Amazing. I want to take us back, I know you mentioned residency training. Based on your experience coming from a medical school in India, what were some of the challenges that you faced as an international medical graduate?

Dr. Gia Merlo (09:02): Oh, great question. It's not a past tense, it's still current. I think some of the challenges are still there. I've been in conversations where, because I don't have an accent and people assume that I'm American, I grew up here, that I've heard disparaging things being said about international medical graduates just on the sly. That, "They don't know as much, they're not as engaged as much." It's hard. It's a hard conversation. You meet somebody, hang out with them, go out to dinner, and then they're talking disparagingly about you, without knowing they're doing that. It happens to me all the time, even now. That sort of stigma, bias, really misinformation that's out there about who we are, whether we're international or here. I think, what's the number, 25% of physicians in this country are international medical graduates? It's a huge number. I think that that in itself was a huge problem.

(10:12): Outside of that, once I could feel comfortable owning who I was and acknowledging to others, I think there are pieces of education that you get when you do the four-year college and then go to medical school that many of us that came from international spaces, I told you, I went straight from high school to medical school, that you miss out. It was a learning curve a little bit. I feel I was very rounded in my education, had a very solid high school experience, but still. But still, there were things that you just didn't know, you didn't know what you didn't know.

(10:54): Besides that, I think that most international medical graduates are the same age or a little bit younger when they start residency, so you may be in a different place, stage in life as well. I went to medical school in a very conservative part of India where you dressed a certain way, you behaved a certain way. One of my first experiences that I love to talk to people about is what eye contact even meant in my medical school. It's changed now, but when I was in medical school, if the professor spoke to you, you looked down as a woman. You didn't make eye contact with a man, especially if it was a professor. I remember the first time when I was in medical school, the professor was saying something to me and I kept looking at him. He looked at me like, "Why are you being so aggressive?" I said, "I'm just looking at you." I didn't realize that was aggressive, but that was viewed as ....

(11:54): Just changing the way we communicate, what's important. I was, "Yes, sir. No, sir. Yes, ma'am. No, ma'am." I was very formal with my professors, which was very different than what I was seeing was happening in residency.

Dr. Anjali Gupta (12:11): Yeah, a whole different cultural context to get used to as well. In your recent years, you've been very active with lifestyle medicine. Tell us a little bit about that.

Dr. Gia Merlo (12:26): Great, great. Thank you. That medical professionalism course I was telling you about I taught at Rice University, brilliant, brilliant premedical students. I think something like 50% of the students that come into Rice want to be physicians and 15% of them end up being physicians. It's just a really rich group of kids that the metrics were also 100%. I remember my first class, I asked them to raise their hands if they were valedictorians and salutatorians, and almost everybody raised their hand. It's just really brilliant, brilliant kids. I really, through that, learned quite a bit of what I thought they needed to learn before they chose and as they chose to become physicians. Because most of them, if they wanted to be physicians, they were going to get into medical school. It was for them to decide if they wanted a good fit. That was a 14-week course in undergraduate school.

(13:19): What ended up happening was I had this module on nutrition and another module on physical activity, because as a group, we tend not to know this, we don't teach this in medical school, but we also don't take care of ourselves because we're running, and we're stressed, and we're eating on the fly because we're so overwhelmed with responsibilities. As I was teaching that, I realized ... My office manager said to me, a lovely woman who is a physician now, Olivia. She said, "Dr. Merlo, I think there's a group that talks the same stuff you're talking about. Maybe you want to go attend that." I attended a conference on lifestyle medicine and it just spoke to me and resonated with my soul.

(14:04): Basically, lifestyle medicine is about the fact that ... It's using conventional medicine, so the same way that we look at psychopathology and pathology period, in the conventional medicine lens. Not like a complimentary, alternative medicine. It's taking that conventional medicine lens and saying, "80% of chronic diseases can often be prevented and many times reversed by lifestyle interventions." The data is there. The evidence is there but we're not, as a group, bringing that up with our patients and using those modalities that are available. Usually on the lines of nutrition, physical activity, stress management, sleep, substance use, decreasing the mitigation around that. Those are the lenses what lifestyle medicine focuses about, we call it pillars. I think it really helps. We now know that we can take things like sleep and how that can help with depression. How exercise and nutrition can actually help with depressive episodes.

Dr. Anjali Gupta (15:20): You started to talk about this a little bit. We know that the mind-body connection is a strong one and your textbook on lifestyle psychiatry just came out in December 2023. But can you talk about these basic tenets of lifestyle medicine, how they relate to this expanding field of lifestyle psychiatry?

Dr. Gia Merlo (15:41): Beautiful, thank you. What I did was, once I joined the lifestyle medicine movement, I said, "Where are the gaps? Where can I help?" What I really wanted to do with that is expand the reach of what we're talking about lifestyle medicine.

(15:55): I see lifestyle psychiatry and I see it's a bidirectional. If we have a mental health disorder, it also affects us in our brain and it affects our physical state. The American Heart Association actually released something called Essentials Eight. What they're saying is we cannot deal with heart health if we don't also deal with mental health. They've acknowledged this and this is a core part of what they think needs to happen in the heart. Also, in the same breath they say, "If you don't deal with mental health, you can also get heart problems." That bi-directionality is really where lifestyle psychiatry sits.

(16:41): In addition, I really wanted to take some of the psychological constructs that we've developed as psychologists and psychiatrists, about what we can address with personality, maybe some of the blocks that we have in our own structures of emotion and the way that we're thinking. How many people do we know have said, "I want to be healthier, I want to eat healthier food, I want to not be overweight or obese anymore," but yet, we don't actualize that and we get stuck. That's what I really wanted the lifestyle medicine movement to hear from us, that psychiatrists and psychologists, on techniques and ways that we can actually do that.

(17:25): The second major part of that is in New Zealand and Australia, our compadres over there, the psychiatrists there, have developed guidelines for treating depression and anxiety, and bipolar disorder, with lifestyle interventions. They have the guidelines and I hope to be able to do that with the American Psychiatric Association as well. For some patients, who they're mild, it may be just what you focus on for some patients. But for the majority of the patients, it will be in addition to the other tools that we have.

Dr. Anjali Gupta (18:02): Right. I just wanted to clarify that a little bit, where medication and therapy would still be first line treatment. But perhaps in addition to those therapies, there might be additional ways to help.

Dr. Gia Merlo (18:17): Absolutely. It's interesting because, in my clinical practice, some patients are resistant to ... If they're mild, if they're mildly depressed, and we would have recommended psychotherapy for them, then if they're still, there's a waiting list, there's all these other barriers that may be there, then we still have tools that we can offer them, which would be the lifestyle psychiatry tools. I think it has a place within all of our tools that we have available.

Dr. Anjali Gupta (18:52): I know one of your current leadership roles is president of the Lifestyle Psychiatry Caucus for the APA. How has the concept of lifestyle psychiatry being received by those within the field of psychiatry and also more broadly in medicine?

Dr. Gia Merlo (19:12): Beautiful. Thank you, thank you. I was so thrilled when the board approved the Lifestyle Psychiatry Caucus. The good news is our president elect, Dr. Vis, Dr. Viswanathan, has now announced in my last Caucus meeting that his presidential theme for our annual meeting in 2025 will be Lifestyle Interventions for Physical and Mental Health.

Dr. Anjali Gupta (19:41): Amazing!

Dr. Gia Merlo (19:43): The answer of your question is I think it's pretty well received here at this point. I'm really excited that we are going to have that opportunity to do that. It's just something that we can really ... Before, we only had psychotherapy, we had psychoanalysis, we had Freud, we had the Freudian, and then we developed all these medications. This is another way of maybe adding another tool in that toolbox. We had psychotherapy, we have medications and we need, yes, yes, yes, and yes, but maybe we can also say, "Let's talk about what their lifestyles is," and empowering the patient to have some partnership in what they're doing that may actually help their mental health.

Dr. Anjali Gupta (20:25): What I love is empowering them, even though they're probably coming to us as psychiatrists for their mental health, we're also, by introducing those things, helping their physical health as well.

Dr. Gia Merlo (20:38): Right. Yes, yes. Absolutely. The data is compelling. I'm hoping that, as it catches on and the information gets more out there, that we're able to actually understand it and it'll be obvious to us. Because I think many of us already recommend these things, but having the data behind it and having the articles right there for you to be able to talk about it, that's what's really compelling about this movement.

Dr. Anjali Gupta (21:03): Yes, it really is. I'm very excited to see where this continues to go. I do want to shift a little bit, and I know we talked about you leading up as president of the Lifestyle Psychiatry Caucus. As you think about women physicians and different types of leadership, what tips or advice would you give?

Dr. Gia Merlo (21:30): I think that, for me ... I've come from always feeling like I have to prove myself. I think that, if I just want to make it real, I would say that from a more general tip that I would give someone like me, that's always felt a little like they need to prove themselves, is just relax, breathe into it. That the only person you have to prove yourself to is yourself.

(21:58): It's beautiful now. I have to start with just also my daughter now, who's 36-years-old, and herself a professional and extremely successful. I watch this new generation, and I watch these women leaders and I'm like, "They don't have that chip on their shoulder that I felt like I had." I'm really, really inspired by them. I think for me, that what the learning lesson is you can learn from so many people, experience is just one part. I love to learn from the new generation.

(22:36): I love to learn and build teams, and focus on what other people's strengths are, so that as a whole, you come together. I don't think we can lead in the old fashioned way independently, with a paternalistic idea. I think it needs to be flattening the hierarchy a little bit, and pull people together, and elevate other leaders that you're seeing so that you can actually get each other's back but also learn from each other.

Dr. Anjali Gupta (23:06): You talked a little bit about this new generation of women. What are some of the challenges you think that perhaps ... I know that women have come a long way. As physicians, we are now 55% of medical school students. What do you see as some of the challenges that surprise you that are still there, that you think we would have maybe come further along on?

Dr. Gia Merlo (23:43): Great question. I think some of them ... It's part of the angst of the human condition, also. In a traditional marriage, we birth the children, we are mothers, we have that maternal instinct. That's so innate, that's part of who we are. Many of us women have partners who may not be earning as much. I think that it gets very, very complicated and they still come home from work, and do all the traditional roles that women have historically done. I think that it started to shift, but I see that it always surprises me when I see a woman who still needs to be the primary in every aspect in the home and the workplace. It's just an untenable position to be. I know as a single mom, I had to do it and it was very hard so I understand how difficult it is.

(24:51): I would love to see women and men both be able to really be equal in the home, when they come to responsibilities and what they do. I think as this new generation learns and teaches us how they're going to do this, I think we need to listen carefully and continue to evolve in how we conceptualize the family and how we move it forward.

Dr. Anjali Gupta (25:18): If you were talking to your younger self, what are some of the things you would tell your younger self, having gone through this journey that you have now?

Dr. Gia Merlo (25:28): That I was good enough. That what I was doing was good enough. Having my daughter in daycare did not take away from our relationship. Yes, I may sometimes have only seen for an hour a day. Yes, I did my rounds and didn't pee the whole day because I needed to get to daycare at 6:00 and pick her up, and sometimes I was late. Yes, she got mad at me, but I was good enough. Not to be feeling shame about it and beating myself up about it, but just understanding that that in itself was a process that could teach my child resilience, teach my child how we problem solve.

(26:09): I look at my daughter now and I see how hard she works, and I'm like, "No, have more time. Enjoy yourself." But I'm like, "Oh, wait. Where did she learn that? Where did she learn that?" That's a good thing, it's a good thing.

(26:22): I think that the biggest lesson is you are enough. You are enough, we are good enough. The Winnicottian sort of idea, the good enough mother, the good enough human, the good enough woman and not be so hard on what you're doing and not doing.

Dr. Anjali Gupta (26:39): So well said. I know you're working on yet another book on lifestyle psychiatry. Tell us a little bit about it. How will this one be different than the last one?

Dr. Gia Merlo (26:51): Yes. At this point, what I haven't done is written a book for the general audience. Lifestyle Psychiatry Book is a textbook, it's a lot of evidence, it's written like a journal article. It's textbook-y, it's academic. What I'm doing now is writing a book for a general audience. I have so many lifestyle medicine physicians that are asking me to take what I've done and translate it to a digestible term, "Don't use the word transference without describing it," those type of things. "Don't talk about neuroticisms unless we explain what that means." That's what the book is.

(27:32): It's for a general audience. What I did in Lifestyle Psychiatry Book, I translated that. People can pick it up. It's a self-help book, so to speak. I put myself in it, I put a lot of my own stories. I talk about some of the missteps that I've made in my life and try to do it with a little bit of humor. But I do reveal a lot of my errors and my mistakes, and hopefully people can resonate with it and not be so hard on themselves because I survived it, too.

Dr. Anjali Gupta (28:06): Well, I look forward to that. When does that release?

Dr. Gia Merlo (28:10): That should be ... I have pens down in three weeks, so I'm going to crunch. It will be in print in May.

(28:20): There's two major lessons that I think are really important at this part of my career that I want to impart to others is there's nothing wrong with that four letter word called love. That we go into this profession, we are a healing profession, that we love our fellow people, humanity, and that's why we want to help others. But the other thing is also that we struggle, and for good reason, because of self-disclosure issues as a profession, especially psychiatrists, with talking about our own transgressions and our own issues. I talk about some of the trauma in my past and how that's informed who I am and helped me evolve more, and helped me become more empathic to others. I do that as well.

Dr. Anjali Gupta (29:07): Well, thank you so much, Dr. Merlo, for taking the time to have this conversation. I really appreciate you being here today.

Dr. Gia Merlo (29:16): Thank you. Thank you. It's been fun, thank you so much.

Speaker 2 (29:27): The views and opinions expressed in this podcast are those of the individual speakers only and do not necessarily represent the views of the American Psychiatric Association. The content of this podcast is provided for general information purposes only, and does not offer medical or any other type of professional advice. If you are having a medical emergency, please contact your local emergency response number.