Q&A: University CMO Dr. Daniel Silverman

Dr. Daniel Silverman has been the University's chief medical officer and executive director of health services since August. Though trained as a psychiatrist, Silverman spent the last decade involved in designing innovative ways of delivering healthcare to different populations and patients. He received a masters in public administration from the Kennedy School of Government, specializing in strategic medicine and healthcare organizations.

'Prince' reporter Marjorie Censer asked Silverman about alcohol, stress and the future of Princeton health.

'Prince': What has been your impression of Princeton so far in terms of health and wellness?

Silverman: In general, health is very good. The wellness takes more explaining, and by that I mean most of the students believe that their general health is very good to excellent, about 75 percent would answer that on a health survey. But, when you think about wellness in terms of referring to the balance in people's lives and in terms of workload, extracurricular activities and exercise, and good nutrition, it becomes more complicated in terms of answering that. It's of concern.

P: What are your main goals and messages for improving health and wellness on campus?

S: First of all, I would say that one of my major goals is to not focus just on the students but also graduate students, faculty and the almost 5,000 nonacademic staff of the University because they're all part of the Princeton community. And, my approach would be to take the population-based approach: that you define populations within your community. So, the undergraduate students tend to form one population, the graduate students are another because they tend to be older, the faculty and the staff are demographically quite different than the students . . .

So, for instance, with the students at the undergraduate level, they would say, and they do in the health survey, that the number one health problem on campus is stress. And they would generally say that the next most important concern is eating disorders, or eating concerns. And, after that, they say generally, alcohol, depression and then finally nutrition would be the top five concerns that they have.

P: What would you say is the biggest health problem on campus, maybe combining populations?

S: I think it's stress, a sort of lack of balance in people's lives and the need to balance the sort of heavy academic and extracurricular loads that people carry with an opportunity for self-reflection, stress reduction, physical exercise, good nutrition, good sleeping habits, and I think a lot of people here are just tremendously dedicated to their academic or institutional pursuits.

But, maybe they need permission to think about other ways to expand their minds and their consciousness and their lifestyle. And, I'm told it's not just the students who feel an enormous amount of stress. A lot of the faculty and a lot of the administrative staff feel very similar. So, I think it's partly because people enjoy being here so much. And it's so stimulating and challenging, but people need to think there may be other ways to learn and expand and improve the quality of their lives.

P: How does Princeton compare to other universities, not only in its healthcare, but also in the health and wellness of its students?

S: I would say that as unique an institution as Princeton is, it's probably more similar to other colleges and universities in terms of the kinds of issues around health and wellness that we're dealing with here. And, in that regard, I joined with Dr. David Rosenthal, who is the director of university health services at Harvard, to put together a group that we call the Ivy Plus group of university health service directors. And, it includes all the Ivy League schools plus MIT, University of Chicago and Stanford University, and we had our first meeting last month. And, we all got together in Boston. It was sort of discussing common concerns and issues and brainstorming, and it was remarkable how similar the schools are in terms of the kinds of issues that they're dealing with and the kinds of programs they're trying to create to address a lot of the health and wellness concerns.

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P: One of the most controversial health issues on campus is alcohol and the alcohol ordinance. What is your view on this?

S: I've been trying to do what I would sort of call an epidemiological case study, and I've been trying to look at the episodes of what I would call high-risk drinking involving Princeton students, and that represents a sort of smaller subpopulation of the total number of students on campus who actually are drinking.

And, my concern is that, I think quite honestly most young adults in America between 18 and 24 will drink occasionally, and most drink very responsibly.

Our concern as a health care organization is really to try and intervene in situations in which people are placing themselves at high risk by heavy episodic drinking or binge drinking. And, so I've collected a series of cases in which students had very elevated blood alcohol levels here and tried to understand not only the amount of alcohol they were drinking, but the context in which they were drinking it.

And, what I have found is that in a majority of these cases, the people with very high and potentially medically dangerous blood alcohol levels tend to be freshmen and sophomore drinkers. They tend to be people who are binge drinking for the first or second time in their lives. They're not experienced binge drinkers, and then, very interestingly, they're almost always in the company of older students, whether it be in a fraternity, sorority party setting or an eating club setting or initiations, the organization or team kind of setting.

And, then, it's my impression that the older students are in some cases enabling the high-risk drinking to go on.

And, my approach is to really begin to think about, and I've had a lot of conversations with students these past seven months, is how to get the older students to take more responsibility and take better care of the younger students in a sense . . .

One of the things I've been proposing to Vice President Dickerson and to President Tilghman and the administration is the idea of creating a sort of student leadership institute on campus. It would really help people develop certain kinds of competencies about how to develop something that I think is a learned behavior that I'll call courage, you know, the ability, the courage to intervene in difficult kinds of situations or for people to take responsibility for each other . . . The goal there would be to really try to address the high-risk kinds of drinking that go on.

P: How are alcohol and stress related?

S: I think a lot of the alcohol may be related to the stress problem. I think people use it either to reward themselves for working so hard or as a way to reduce social anxiety or as a way to become a member of a group.

And, so, as a rule I like to be more of a lumper than a splitter and say that these things are interactive in many ways. And, I think that even stress is too global a concept — that people certainly feel some anxiety about their academic workload or extracurricular activity workload, but on the other hand, I think that people feel a lot of interpersonal stress here and a lot of stress that's perfectly appropriate to where students are in their lives, developmentally . . .

Most of the students here know they can do the academic work and pass the courses, but they're less sure about how they're going to find their own personal identity and a community for themselves. And, they feel a lot of stress about that . . .

So, I think there's a lot of issues that make people feel very stressed on campus, and that probably drives a lot of the behaviors that we're concerned about in a healthcare area. It's probably what drives people to stay up so late and work so hard and stoke up with Red Bull and over-the-counter stimulants, and it's probably what causes people to both work so hard and party so hard. And, it probably contributes to not getting enough sleep, not getting enough exercise, not eating well. It becomes secondary health habits that are related to a lot of the anxiety that people feel.

P: Do you think that this stress is due to an "Organization Kid" environment?

S: Well, I'll tell you what's really interesting to me is that I think it starts well before college. I did cite a study to the cabinet which was of affluent suburban students who feel pressured to get accepted to the best colleges, and that it seems to encourage them to smoke and drink and use drugs as a way of relieving some of the pressures they feel. And, also there seems to be a higher incidence of depression in those students.

What was amazing was that the study was the year between sixth and seventh grade, and what they found was that those students who were under a lot of both parental and internal pressure to excel academically and at extracurricular activities had a higher incidence of using alcohol, drugs, and smoking, and also feeling depressed.

And, that happens well before Princeton. So, if you're looking at middle school kids, it's clear that the trends don't just start here.

P: What have you been doing with emergency preparedness lately?

S: Everything from how do we respond when we found out there was some tainted turkey being served in the dormitories last year to what would we do if there were identified cases of smallpox in the Princeton area, and how we might use Princeton University Health Services and the campus to perhaps do a mass immunization program for the entire Princeton Township and Borough, as well as the campus, to what we would do if there were things like the emergency response center in case of another 9/11-kind of event.

So, we are doing a fair amount of planning and consideration of how we would mobilize and collect resources and what we would do in case of either a campus-based emergency or a New Jersey-based or even a nationally-based emergency. And, so we meet regularly, and we're grappling with all those issues.

P: What made you want to come to Princeton?

S: It just seemed like a wonderful opportunity to combine many of my interests. You know, quite honestly, a lot of the most important health issues on a University campus are things that are relevant to a psychiatric background, like depression, anxiety, eating disorders, substance use and abuse problems. So, a lot of my clinical training and background was very relevant to some of the major issues for certainly student health concerns on campus. And, then this opportunity of really trying to take a population-based approach, so that I could be working with everybody here on campus to improve the health and wellness of every significant population of the Princeton University community was also very exciting. And, then finally, you know, Princeton is such an amazing academic institution, such a vibrant kind of place, it just seemed like just a wonderful opportunity to use a lot of my training and my experience.