A clarinetist I performed with as a high school student later endured a miserable first semester as a conservatory freshman. She had been accepted into the studio of a phenomenal teacher at a prestigious school. While she knew that working with him would mean major changes to her embouchure and overall technique, she still seemed incapable of producing a focused, resonant sound after several months of practice. Even her new teacher began to express concern.
Then she brought her clarinet to the repair shop for a tune-up and discovered that she had been playing on an instrument impaired by a significant but invisible crack. The problem had never been her embouchure—her instrument had been malfunctioning.
One of the reasons that I feel it is so important for singers to understand how your instrument functions is so that when a problem arises, you can discern whether it is an issue of skill or physiology and pursue an effective solution based on that information. If you understand how your voice ought to respond when it is healthy, it becomes easier to recognize when a medical issue is interfering with your singing. Conversely, if it is always a mystery whether your voice will work on a given day, you are likely to develop the chronic hypochondriacal angst so common to our profession.
The most impeccable technique is unfortunately not always sufficient to keep hypochondria at bay. Paranoia about health is rampant in our community, and the strategies singers adopt to avoid getting sick are as far-ranging and idiosyncratic as our voices. So pervasive is this problem that Peter Gelb, general manager of the Metropolitan Opera, reportedly once went so far as to consider commissioning a study to catalog the maladies responsible for company member cancellations.
Such a study would be pointless because as a class, singers are in fact no more vulnerable to illness than the average human. Our paranoid tendencies arise from the simple truth that the professional consequences are far more extreme for us than they are for almost anyone else when we do get sick.
For any given profession, there is a baseline level of health and energy required to perform one’s job well. I would argue that the level of health and energy necessary for adequate performance as a classical singer is higher than for nearly any other occupation. A head cold will not prevent a lawyer or an accountant from turning in a fine day’s work. A dental hygienist can don a face mask and continue attending to patients. Even news anchors or talk-show hosts with a touch of the flu can show up to work, because even if their audiences perceive some hoarseness in their speaking voices, they will be forgiven because they are, after all, human. But a classical singer will not be forgiven if the symptoms of a head cold or flu impact your tone, narrow your range, or cause a phlegmy rattle on certain pitches. When successfully doing our job requires us to maintain perfect health at all times, it’s no wonder that those for whom the stakes are nowhere near as high view us as hypochondriacs.
Another reason for our paranoia around health issues is that a singer who is not healthy enough to perform may receive no pay for weeks of work they have already put in. Opera companies commonly offer contracts providing payment for performances rather than guaranteeing a fee that covers rehearsal weeks. In such a case, a singer who devotes several weeks to preparation but then becomes too sick to go on takes a crushing financial hit. Throughout this book I have argued that we are as much athletes as we are artists, but even professional athletes do not face dire consequences for canceling an event due to illness or injury. An NFL linebacker will not find his multiyear contract canceled for missing a couple of games due to bronchitis; an Olympic skater will not lose corporate sponsorship while recovering from an ankle sprain. But an opera singer who cancels a performance due to illness is likely to forfeit a huge percentage of his or her expected earnings . . . and prompt the general manager of the company to consider studying why we are so much more susceptible to medical issues than it seems we ought to be.
Athletic culture is aware that everyone succumbs to illness or injury from time to time; opera culture views illness as unforgivable.
Singers are thus under tremendous pressure to remain healthy. Our employers depend on it, and our personal financial well-being relies on it. The paranoia this can instill makes us that much more susceptible to anyone marketing a magic pill to guard us against illness. There are no end of herbal supplements, tinctures, and teas that promise a bulletproof immune system. There is a strong temptation to confer with your colleagues, each of whom has their preferred elixir, and to fall down the rabbit hole of adding everything they recommend to an increasingly complex and expensive daily regimen that may do nothing at all to fortify your health, further escalating your sense of paranoia and vulnerability.
I therefore offer two general guidelines for getting through a singing career with a reasonable degree of physical and mental health:
1. Pursue only those strategies for staying healthy that are supported by medical and scientific knowledge, rather than relying on anecdotal advice from colleagues.
2. Understand that even if you do absolutely everything within your power to stay healthy, you will still occasionally get sick.
Singers do not get sick at a different rate than nonsingers. The strategies that doctors recommend to keep normal people healthy can serve us extremely well, as long as we acknowledge how imperative it is for us to follow them consistently.
As I discussed in chapter 8, the education that fitness trainers receive emphasizes the importance of only providing advice that is well within the scope of our practice. We are qualified to offer exercise instruction and perform basic first-aid interventions when called upon, but we are not medical professionals. In my opinion, voice teachers should be similarly mindful of our scope of practice and refrain from dispensing medical advice. Therefore, the suggestions provided in this section reflect widely available medical research as opposed to my own expertise.
Wash Your Hands Frequently.
Keep your hands clean. We frequently come into contact with potentially harmful germs just in the course of day-to-day living. Exposure to raw meat, a colleague with a cold, and countless other things can put us in contact with something potentially infectious, and anything that gets on your hands can end up inside your body when you touch your eyes, nose, or mouth. Hand washing has been shown to prevent up to 20 percent of respiratory infections. The Food and Drug Administration finds that plain soap and warm water is sufficient for keeping your hands germ-free, so there is no need to hold out for antibacterial soap or the perfect hand-sanitizing gel. Wash your hands.
Get Adequate Sleep.
Adults require from seven to nine hours of sleep nightly to support their health and energy levels. Sleep deficiency can compromise your immune system, making you more vulnerable to viruses and infection; it also increases your risk for heart disease, kidney disease, diabetes, and obesity. In addition to supporting your physical health, adequate sleep promotes optimal brain function, improving your abilities to retain new learning and make effective decisions. Rather than burning the midnight oil to memorize your score or plot your next career move, get a good night’s rest. You’ll improve your productivity as well as your chances of maintaining your health.
Drink Enough Water.
As I discussed in chapter 8, proper hydration is essential for your health and physical functioning. Water regulates body temperature, eliminates toxins, and protects joints and tissues. Optimal water intake will vary for each individual. The National Institutes of Health guidelines recommend 3,000 ml daily for adult men and 2,200 ml for women, but there is no need to obsessively measure your fluid intake. If you drink enough water throughout the day to avoid becoming uncomfortably thirsty, you are probably keeping yourself adequately hydrated. Singers do not need to drink a greater quantity of water than average people.
Don’t Smoke.
Smoking is detrimental for classical singing in a number of significant ways.
• Smoking causes coughing. The chemicals in cigarettes damage the cilia in our trachea, preventing them from catching inhaled toxins before they can enter the lungs and necessitating that we cough in order to clear the toxins out again. Coughing can be highly traumatic for the vocal folds and must be avoided when possible.
• Smoking irritates your vocal folds. Smoking dries the vocal folds, prompting a buildup of mucus in the area. It can also cause inflammation that thickens the vocal folds, lowering the pitch and diminishing control over registration.
• Smoking irreversibly impairs pulmonary function. Smoking damages the alveoli, the air sacs in the lungs that exchange carbon dioxide for oxygen. As I explained in chapter 2, our ability to sustain long phrases depends far more on oxygen satiety than on lung capacity, so diminished oxygen intake will lead to diminished breath management for singing.
Additionally, the surgeon general finds that smoking causes lung cancer, heart disease, and myriad other ailments that could prove problematic for your singing career.
Maintain Adequate Humidity While Sleeping.
Breathing in dry air overnight can desiccate the skin of your nasal passages and throat, causing minuscule cracks that leave you more vulnerable to bacterial and viral infection. Just as cigarette smoke damages the cilia in your lungs, dry air can damage the cilia of the nasal and sinus cavities, limiting their ability to guard your airways against toxins. Use a hygrometer to monitor the humidity in your bedroom and run a humidifier overnight when necessary. Aim for 40 percent to 50 percent humidity during warmer months; in colder months, maintain the highest humidity level you can without allowing condensation to form on your windows, as too humid an environment can promote bacterial growth. If you find that you are unable to keep the humidity over 20 percent due either to excessive dryness or risk of condensation, spend some quality time with a steam inhaler upon waking.
Use a Saline Nasal Rinse Daily.
A saline rinse washes away thickened mucus and toxins, helps keep the nasal passages open, reduces postnasal drip, and promotes healthy cilia. It keeps the area clean and moist, and it can flush out germs before they have an opportunity to cause an infection. Combine a premeasured salt packet designed specifically for this use with the prescribed quantity of distilled or boiled water, not tap water. Either a neti pot or a squeeze bottle will do the trick.
Protect Yourself during Air Travel.
From a health standpoint, air travel is taxing in numerous ways. The air in the cabin is pressurized to mimic high-elevation conditions; it contains a smaller quantity of oxygen, which would be present at high elevation and is also quite dry. These conditions make it difficult to sleep and stay adequately hydrated, and the recirculation of air through the cabin enables passengers for whom optimal health is not a high priority to share their germs with you. It is up to you to mitigate these adverse conditions as best you can. Wearing a surgical mask will protect you from stray germs; wearing a HumidiFlyer will help keep you hydrated. Keep plenty of water handy—pick up a big bottle once you are through security, or pack an empty bottle that you can fill before boarding in case bottled water is not available on the other side. Do your best to plan travel so as to avoid having to fly and then sing later that same day. If you have an audition, fly the previous night and sleep in a hotel. If you’re on tour and have to perform on consecutive days in different cities, catching a red-eye flight after a show so that you can sleep and wake up in the location where you will next perform will likely leave you better rejuvenated than having to travel and perform in a new location.
Keep Current with Immunizations.
The Centers for Disease Control and Prevention recommend that all adults be vaccinated annually for influenza, every ten years for tetanus, and once for chicken pox. Other vaccinations may be recommended depending upon age and individual risk factors. Schedule a flu shot each year as soon as it becomes available, and ask your doctor whether there are additional immunizations he or she recommends. You will almost certainly be exposed to people who already have the flu because it isn’t nearly as important for them as it is for you to avoid catching it or to stay home while they recover. Protect yourself.
Be Smart about Alcohol Consumption.
If drinking is something you enjoy, get to know the way your body and mind generally respond to alcohol. Establish guidelines for yourself and follow them to ensure that drinking never poses a problem for your singing.
Don’t drink on the job. Classical singing demands your very best physical and mental coordination, and a small amount of alcohol will impair your motor control and cognitive abilities to some extent. Alcohol also causes dehydration, which will have a negative impact on vocal function. Never drink before a coaching, rehearsal, or performance. While alcohol may reliably settle your nerves in social settings, drinking is not an effective way to contend with performance anxiety.
Don’t do the crime if you can’t do the time. In addition to poor coordination and dehydration, heavy drinking can lead to nausea, acid reflux, headaches, and difficulty sleeping. Know your limits and avoid drinking beyond your ability to recover in time for a rehearsal or performance; for many singers, that may mean abstaining when you have to sing the following day. If drinking or hangover symptoms have impaired your ability to do your job on more than one occasion, seek evaluation for addiction.
Indulge intelligently. Artists tend to be hedonistic—if we don’t live it up at least a little, we won’t have all that much to sing about! Deprivation for its own sake will not support your health.
Speed your recovery. Hangovers result from a combination of dehydration, starvation, and shock. You can avoid or minimize these symptoms by drinking plenty of water, avoiding drinking on an empty stomach, and taking a vitamin B complex supplement prior to going to sleep.
When you find yourself with an affliction that threatens to impede your effectiveness as a singer, your two highest priorities are to get well as quickly as possible, and to ensure that your condition does not worsen to the point that it turns into something more nefarious. For example, without early intervention, a cold or flu can develop into a sinus infection; a bacterial infection can develop into a fungal infection. Best practices for both of these priorities are the same.
• If something harmful has gotten into your body and there is a medication available that will get it out of you, take that medication.
• Keep your respiratory passages open.
• If you are coughing, do what you can to stop.
• Address gastroesophageal reflux as aggressively as possible.
Medicate When Necessary.
If you have an ailment that can be alleviated by medication, acquire and administer that medication as soon as you can. Do not wait to see whether you start to feel either better or worse. If you have a bacterial infection or strep throat, the sooner you take an antibiotic the sooner you will feel better; you will also minimize the possibility that your symptoms will worsen. If you are concerned about overprescription of antibiotics, the solution is to refrain from taking them when you do not need them. If you have a bacterial infection, take them—you need them. If you catch the flu, take Tamiflu if possible. It will shorten your illness by a valuable day or two, and that can make the difference between being able to perform and having to cancel. Recovering from the flu more swiftly may also prevent you from developing a sinus infection.
Keep Your Respiratory Passages Open.
If you are experiencing nasal and/or chest congestion, pursue specific symptom relief in order to breathe adequately. Pharmaceutical companies produce quite an array of multisymptom medications, so be discerning in your selection of over-the-counter (OTC) medications and take only those that will treat the symptoms you are experiencing. Some medications in the multisymptom formulas may yield undesirable side effects such as impaired cognition or physical coordination, which will make it difficult to do your job well. If you don’t need them, don’t take them.
Treat Nasal Congestion.
If you have nasal congestion, take a nasal decongestant. Nasal decongestants reduce swelling by constricting blood vessels in the nasal cavities and are available in both topical and oral forms. Sudafed remains the gold standard of oral decongestants; it is available in the United States at pharmacy counters with valid identification and without a prescription. Steroid nasal sprays are available for nasal congestion resulting from a chronic condition. Consult your physician to determine whether a topical or oral decongestant or steroid nasal spray will best meet your needs.
Treat Chest Congestion.
If you have chest congestion, take an expectorant. Expectorants loosen congestion in the airways and lungs by increasing the hydration of mucous secretions, making them easier to expel. Guaifenesin, the active ingredient in Mucinex, is an expectorant that also has muscle relaxant properties and thus makes coughing both more productive and less potentially damaging to the vocal folds.
Treat a Runny Nose.
A runny nose can be annoying, but it will not necessarily keep you from singing well; however, antihistamines, which provide symptomatic relief for a runny nose, can make you feel drowsy or disoriented, compromising your coordination and alertness and making it difficult to sing. If you require antihistamines to manage allergies or are experiencing painful postnasal drip secondary to a sinus infection, work with your physician to identify the option least likely to cause excessive drowsiness. Otherwise, I recommend just blowing your nose. I also recommend avoiding multi-symptom OTC medications that include an antihistamine—treat only those symptoms that are causing you actual difficulty.
Treat Fever, Pain, and/or Inflammation.
These three symptoms often arise together. Whether and how you choose to treat all of them requires some consideration. According to a recent National Institutes of Health study, there is increasing support for allowing a low-grade fever (less than 103°F) to run its course rather than using medication to suppress it. However, if these symptoms are causing you intolerable discomfort, you have some options. Medications with acetaminophen suppress fever and relieve pain. Nonsteroidal anti-inflammatory agents (NSAIDs), which commonly include ibuprofen, suppress fever, relieve pain, and reduce inflammation. If singing is painful, do not take medication to make it easier to sing through the pain—allow yourself some rest.
Avoid Coughing.
If you are coughing, it is vital for the well-being of your voice that you do what you can to stop. Coughing can be traumatic to the vocal folds, potentially leading to hemorrhage or tears, so take a cough suppressant. Dextromethorphan, the most common active ingredient found in OTC cough suppressants, works by inhibiting the cough reflex, but I have personally found it to be inadequate for the needs of singers. I recommend working with your physician to identify a non-drowsy cough suppressant that will serve your needs during the day, as well as a narcotic option to help you sleep through the night without coughing. Benzonatate, the active ingredient found in the prescription cough suppressant Tessalon Perles, suppresses coughs by numbing the stretch sensors in the lungs. If you can safely take narcotic medications, Hycodan is an effective overnight cough suppressant.
Address Gastroesophageal Reflux Disease Aggressively.
Gastroesophageal reflux disease (GERD) is a chronic condition wherein partially digested food backs up into the esophagus, resulting in heartburn and exposing the vocal folds to potentially devastating stomach acid. The symptoms of GERD can often be managed by adjusting your diet to cut back on acidic foods and beverages and refraining from eating too close to bedtime; however, it’s hard to be disciplined when you find yourself famished after a performance and are offered rich food and cocktails at a late-night reception. If diet and lifestyle changes are not sufficient to eliminate your symptoms, the next line of defense is medication. Proton pump inhibitors are effective for reducing stomach acid; however, as of this writing their efficacy and safety have yet to be studied for long-term use. In extreme cases, surgery is sometimes necessary to get GERD symptoms under control. If you are having reflux issues, see a gastroenterologist immediately for diagnosis and treatment.
This section primarily addresses the needs of U.S. residents at a moment when health insurance laws and services are in flux. However, the basic priorities expressed here hold true for singers worldwide.
It is of vital importance to acquire a health insurance policy that will facilitate swift, affordable access to an otolaryngologist whether you are performing at home, with regional companies, or abroad. Achieving this may be difficult and/or costly, but it will greatly benefit not only your health but also your peace of mind.
If you are on the road and need to see an otolaryngologist but have a health insurance policy that offers only geographically restricted areas of service, such as a health maintenance organization (HMO), you will have to go home in order to receive care. In such a case, you may have to choose between forgoing treatment and canceling your gig. If your plan potentially covers a visit to an otolaryngologist where you are working but requires a referral, that will delay your ability to access care. Ideally, what you need is a policy that offers nationwide in-network care, without a need for referrals. Most of those policies take the form of preferred provider organizations (PPOs). Such a policy will not only ensure timely access to an otolaryngologist but will also minimize the necessity of visiting an emergency room should any health issue arise while you’re on the road, as you will be covered for visits to other local specialists as well. Unfortunately, not every state offers PPOs on the exchange, but you still may be able to find a policy with out-of-network coverage.
If you want ready access to an otolaryngologist when you’re out of the country, then in addition to a PPO with nationwide in-network coverage you will also need a supplemental policy for international travel. Such policies are available on a per-trip basis or on an annual, renewable basis. If you will be performing abroad for an extended period of time, you may wish to look into obtaining an insurance policy from the country where you are working. Either way, seek a policy that will cover you on its own rather than first billing your primary insurance, as this will save you from a potentially overwhelming bureaucratic burden.
Primary Care
Seek a primary care physician who understands your priorities and the level of health you must maintain in order to do your job well. If you enjoy excellent rapport and develop a high level of trust with your doctor, you will feel comfortable turning to him or her when you need assistance and be accepting of his or her advice, rather than endlessly googling and self-diagnosing symptoms as they arise. The right doctor will be on the lookout for things that might not bother an ordinary person but are potentially hazardous for your career, such as medications with side effects that are detrimental to your voice or procedures that could have a long-term impact on breathing or phonation. The right doctor will help you seek options that will support rather than impair your instrument.
When to See a Doctor
The earlier you receive a diagnosis and treatment for an illness, the less it will interfere with your work. When possible, I encourage you to see your doctor as soon as you experience symptoms for which medical assistance would prove useful.
High fever. See a doctor if you have a fever of 102°F or higher and are unable to reduce it with OTC medications.
Painful sore throat. There are a number of things that can cause a painful sore throat, many of which are best resolved with a prescription medication. It’s vital that you find out what is really going on and access the best possible treatment.
Thick yellow or green mucus. Mucus that is clear, white, or very pale yellow may indicate a common cold, but if it is dark yellow, green, or blood-streaked it would be wise to see your doctor to find out whether you have an infection requiring antibacterial or antifungal medication.
Persistent diarrhea. Diarrhea that lasts for two days or more puts you at risk for dehydration, among other things. Seek medical assistance to resolve it swiftly and rule out the possibility that it is symptomatic of a more serious condition.
When to Cancel
When your voice does not feel 100 percent healthy and functional, the decision of whether or not to go on can be a difficult and personal one. There are a number of factors to consider. If your singing remains competent though not transcendent and you will forfeit your paycheck by canceling, the right choice for you may be to perform. You may risk a poor review, but if you need the money and enjoy a reputation that is strong enough to survive a ding or two, you may elect to go on. However, if your voice is impaired to the point where you cannot access the range necessary to perform a role, your cords are not closing adequately to produce a focused sound, or you are coughing uncontrollably, you must cancel—not only for the sake of the production but also to avoid injuring yourself.
Be a responsible colleague and cancel rehearsals, lessons, and coachings if you have an illness that may be contagious, even if you are not presenting with symptoms that prevent you from singing.
Coping with Anesthesiology
If you need a procedure requiring general anesthesia, have a conversation with your anesthesiologist to explain your priorities and request advice. Intubation must be undertaken with care in order to protect your vocal folds, and if the anesthesiologist knows you’re a singer it may be possible to make some accommodations to minimize any chance of discomfort or harm. For example, there are some surgeries that are typically performed with general anesthesia but could instead be accomplished with an epidural or a spinal block. The anesthesiologist may be able to use an anesthetic facemask in lieu of intubation. When intubation is necessary, he or she may be able to utilize a smaller tube and ensure it is inserted as gently as possible.
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It is of paramount importance for you to maintain as healthy a lifestyle as you can, but it is also important that you approach health matters with a spirit of pragmatism rather than paranoia.
• Understanding how your instrument functions will help you discern whether vocal problems stem from technical issues or medical ones.
• Respecting your body as you would an heirloom instrument will motivate you to think of healthy lifestyle habits as a part of your job.
• A strong relationship with a primary care physician will incline you to seek timely medical care when you need it and remove the temptation to self-diagnose and self-medicate.
• Researching and acquiring adequate health insurance will ensure your ability to protect your instrument both at home and on the road.
I’ll close this chapter with some final thoughts on supplements: At this point, tinctures and teas are as much a part of classical singer culture as the scarves we layer around our necks whenever the thermometer drops below 68°F. While they may not defend us from illness or speed our recovery as we might wish, they can offer a measure of comfort and reassurance. So I encourage you to continue enjoying your echinacea, licorice, or whatever lemon-honey-ginger-cayenne concoction you swear by. Just understand what it is actually doing for you. Teas and tinctures provide topical warmth, stimulation, and relief—they change the sensations you are experiencing inside your mouth and throat. If your mouth is dry, they might restore a sense of moisture; if your throat is sore, they may provide some subtle numbing of the pain and encourage relaxation of muscles that feel tense from coughing. The herbal remedies you favor can be a vital component of the self-care you engage in to restore you to health, so long as you use them to supplement rather than supplant good overall lifestyle habits and expert medical care.