Dr. Anthony Jahn, an otolaryngologist and volunteer medical director for the New York Metropolitan Opera, introduces you to the art of caring for professional singers. What are the idiosyncrasies of providing care to this select population, who must be doggedly devoted to preserving strong health and maintaining good overall occupational status, most specifically those breathtaking voices? Host Dr. Michael Greenberg talks with Dr. Jahn about the delicate balance of prescribing steroids to elite vocalists, their exposure to alternative medicines and belief systems, as well as the role of placebos in mollifying superstition among high-level performers.
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A Night at the Opera: Medical Care for Professional Singers
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A night at the Opera, it’s more than a classic Marx Brothers film. It is the second career of our guest today. When illness strikes at the met, he makes his entrance. You are listening to Reachmd XM157, the channel for medical professionals. Welcome to the Clinician’s Roundtable. I am Dr. Michael Greenberg, your host, and with us today is Dr. Anthony Jahn, the New York Metropolitan Opera Volunteer Medical Director <____>.
Welcome Tony.
DR. ANTHONY JAHN:
Hello there.
DR. MICHAEL GREENBERG:
Well, tell us about yourself. Tell us about your job, without being specific. You just don’t treat singers, you kind of treat the whole audience too, don’t you at times?
DR. ANTHONY JAHN:
Yes, we do. Well, my background in my practice is an otolaryngologist and I am one of the doctors at Metropolitan Opera who provides medical care during performances and rehearsals and I have been there now for 25 years and I am not the oldest one there, so it is a job that people tend to hang on to. We have a different doctor covering performances every night and we basically look after the stage, the orchestra, and the audience. So I would say a lot of it is, you know, primary care and then taking care of mishaps, but we do get to see of course the performances as well and the performers when they are having problems, so that has really become a big part of my practice.
DR. MICHAEL GREENBERG:
How did you first get connected with the Opera?
DR. ANTHONY JAHN:
Well, when I moved to New York in 1979 from Toronto, which is where I did all my training, my wife who is a professional musician had an old friend also from Toronto, who is a violinist, whose husband was one of the administrators at the Metropolitan and of course there was a whole group of doctors in place and I started off kind of at the bottom of the line covering my night and then as time passed and people left and retired, I moved my way to the top.
DR. MICHAEL GREENBERG:
Do you have to go on stage in audition, show your physician skills and sing?
DR. ANTHONY JAHN:
If they heard me sing, I wouldn’t be there.
DR. MICHAEL GREENBERG:
Dealing with divas, I have met some artistically gifted singers too and performers, are they different than you and me, I mean what kind of special needs do they have and what <_____> do they have that you have to contend with.
DR. ANTHONY JAHN:
Well, yeah, I would say that most professional artists are different than you and I. They are devoted to their art. The art is very difficult. It does take many years to learn and it takes, you know, hours a day to keep up, and they are very dependent on it, that's only their livelihood. They are also very in-tune with their bodies. Singers have a much higher degree of proprioception in the facial area, in the skull area, than you and I would. A lot of the singing is not monitored by listening, but by proprioception and by bone-conducted sound, so they are very often aware of very, very minor changes in the voice before you and I could hear it. So, one of the things that I have learned treating singers is to listen to them when they complain. You know, it is very easy for physicians to know what they know and to just ignore everything else, and a singer may come in and say, “You know, I find when I hit a certain note, it doesn’t feel right.” Now, if you bring that complaint to most physicians, they wouldn’t know what to do with that, but you just have to listen to them and accept that. They are also very sensitive; they have to be, you know, they basically put their heart out every night and, you know, I am sure that you and I are fine physicians, but we are not auditioning with every patient. They are auditioning with every performance, there is always somebody listening and each performance in way is responsible for furthering their career, so you just have to love them.
DR. MICHAEL GREENBERG:
Well, you weren’t trained, I am sure, in your residency about when a singer comes in and says “when I hit, I see something doesn’t feel right in my sinus,” where do you pick up that training, along the way or is there is some special training that you had for this?
DR. ANTHONY JAHN:
Well, no, there is no special training. I think the first thing is that you need to have an interest in this and my interest came from music. I started off light as a pianist and I have been around musicians most of my life and this is something that has always attracted me to the two things that led me to the specialty of ENT where hearing, which is the ear and the voice, so this has always been kind of, you know, on the back burner for me. I have worked with a couple of wonderful professional voice laryngologists over the years, one was Dr. Wilbur Gould, who is a very well known specialist in New York and the other one was Dr. Eugene Grabscheid also in New York, and so I spent a lot of time in their office taking care of singers and just learning to work with them and then when I started to attend the Opera, I had a chance to learn the repertoire and the different roles and the whole thing just kind of came together.
DR. MICHAEL GREENBERG:
Is there is a difference in the medical needs between those artists who sing opera as compared to those who are in musical theater.
DR. ANTHONY JAHN:
Yes, there is. This has been described years ago by someone, I don’t remember who it was, and the comparison was that opera singers are the high jumpers with the sprinters and musical theater singers are the marathon runners. To perform in musical theater is much more tiring. These people often have to sing 8 shows a week and depending on what the venue is, there may be not be a cover, so they have to go on, they are the show and it’s just a very, very tiring and wearing way of singing. The technique of course is also quite different. In musical theater, there is a technique called belting and I don’t know if you know a lot about singing, but typically if you sing in two different voices, sometimes three, the chest voice which is the lower notes and the head voice which is the higher notes. Some people also sing in a falsetto on the very top.
DR. MICHAEL GREENBERG:
Yeah, that is how we do around the studio here. We just sing in falsetto all day long.
DR. ANTHONY JAHN:
I am sure you do all the Beach Boy hits, but with belting, what is done is the chest voice is pushed up into the head voice range, so it is an unnatural stressful way of singing and this is what musical theater demands, so these people tend to have problems. They have chronic problems and they can’t take a week or two off.
DR. MICHAEL GREENBERG:
I have always wondered how singers or performer feel about surgery, how scared they must be and I heard a rumor once that Enrico Caruso had his tonsils out 9 times, I don’t know if this is true. They grew back and each time his voice got better, but what are the steps that you have to do to protect the egos and the voices of these performers, if you have to do surgery on them?
DR. ANTHONY JAHN:
Yeah, there are several things. One is that of course nobody normally wants to have surgery unless you have, you know, <_____> and singers definitely don’t want surgery. It means time off work, it means often a financial handicap because their insurance is not always so good, and most importantly any surgery around the upper airway, there is always a big concern that it is going to change the voice. So I think there is room for surgery in singers, but it needs to be very judicious and very clearly indicated and my practice is to eliminate every other possible way of treating things prior to recommending surgery. Now, there is another aspect to surgery for singers, which is anesthesia and intubation, and if a singer has to have her gallbladder out, then there is a big concern about being put to sleep and having a tube put down between the vocal folds and the possible damage from that, so I usually recommend to those patients if possible to have the intubation done expertly rather than by somebody in training. I recommend that the smallest tube be used, which in a woman would be about size 5. I suggest to the anesthesiologist that they extubate the patient deep, so they don’t start phonating on the tube and if possible, I recommend the use of a laryngeal mask, which avoids the need to put the tube between the cords.
DR. MICHAEL GREENBERG:
How about steroid usage in vocal performers? Are steroids used a lot, I have heard about that?
DR. ANTHONY JAHN:
Yeah, I think steroids are actually overused. I am not sure about the other specialties, but in treatment of professional singers, you know, steroids are the, you know, “the refuge of the scoundrel.” If you don’t know what is going on and somebody is hoarse, you give him some steroids, it can’t hurt, but actually it can hurt because of several reasons. First of all, you can abuse steroids and get the usual side effects from it, but also it does decrease edema on the vocal folds and it gives singers a false sense of security and so one of the defense mechanisms, which is the sensation of discomfort or pain is taken away, so they will often over-sing and cause more damage. The other problem I see certainly with the international singers that we see is that they travel all over the world and they get shots, and somebody may come and see me and last week, they were maybe in London and they were hoarse and they got a shot and they don’t know what was in the shot, it was probably some kind of cortisone. The week before, they were in Munich and they were walking around with all these drugs, different forms of steroids in their body, so you know, I think this is a very dangerous thing. I do use steroids; I use steroids in singers who have a very important performance that cannot be canceled. I will often tell singers if it permits or a rehearsal can be canceled, they need to prioritize what is, you know, career making versus less important. The other thing I tell singers is to know what they are being given, because there is a sense of trust. You walk into doctor’s office; he gives you something, take this, and you don’t know what you are getting. So I always ask them to keep track of what they are being given.
DR. MICHAEL GREENBERG:
That’s not just singers, that’s all of my patients too.
DR. ANTHONY JAHN:
It’s absolutely true and I think that with singers, there is a very special relationship that singers have. They need to be taken care of, they need to trust you, and they almost don’t want to know because in the sense there is more of a placebo affect if you don’t know what you are getting, but I always tell them to find out what it is. Now the last thing with steroids, it is very dangerous in my opinion to give steroids to musical theater people, for the reasons that we discussed before, which is that they need to keep performing and they are going to really not have time to recover. You know, they keep singing on these cortisoned up vocal folds and eventually they are going to get some permanent damage.
DR. MICHAEL GREENBERG:
Let me ask you an off the wall question. Performers of very high calibers doing pretty artistic circles around the world and they meet lots of interesting artistic people who aren't singers. How exposed are these people to alternative medicine and how much do you deal with the theater superstition and kind of out their ideas that are picked up by these peoples.
DR. ANTHONY JAHN:
I think your question is two parts. The first part is with alternative medicine, which I will get back to. The other part is superstition. I have no problems with singers’ belief systems as long as it is not harmful. There was a tradition for Pavarotti that before he wound go on stage, he would look around backstage to find a bent nail on the floor, and so if he found a bent nail, this would signal that his performance would be good. So all over the world, stagehands would scattered bent nails back stage, so he would find one. That’s harmless. There are some injections like vitamin B12, which are harmless; sometimes they are helpful. There is a big placebo effect and I am a big believer in placebo, and the problem with placebo historically was when you were doing a scientific study where you are trying to isolate one parameter that you are studying for, you didn’t want the placebo effect confounding your results. When you are treating patients, you know, where the time is the road, whatever you can use to make that patient feel better is good and placebo is nothing else than the mind and body connection as far as I am concerned and it has a name and a place, in the place of the hypothalamus. If I can convince the patient that what I am doing is helping him, it will help him more. So that’s the part on belief systems. Now, as far as alternative medicine, singers love alternative medicine and there are a number of reasons for that. They don’t normally like traditional doctors and surgery and expensive drugs, and also much of what I see with singers in terms of disorders are really disorders of function and not disorders of structure. You know, on a certain level what I practice is occupational medicine. A lot of the problems singers have relate to how they sing, where they sing, but these are really problems of physiology rather than anatomy and alternative medicine, especially acupuncture, Chinese medicine addresses problems of function in my opinion much better than traditional Western medicine, so I am believer in it, I am a practicing acupuncturist. I use acupuncture daily in my practice and it is a very useful adjunct to medicine and surgery.
Tony, thanks for being our guest today and speaking with us about your second career as the Volunteer Medical Director of the Metropolitan Opera.
I am Dr. Michael Greenberg and you have been listening to the Clinician’s Roundtable on ReachMD XM157, the channel for medical professionals. ReachMD XM is here for you to help professionals who care for your patients. We welcome your questions and comments. Please visit us at ReachMD.com for our newly redecorated website with its on-demand and podcast features, will allow you to access our entire program library including this show. Register on the website and enter promo code “radio” for 6 months of free podcasts and we thank you for listening.
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Overview
Dr. Anthony Jahn, an otolaryngologist and volunteer medical director for the New York Metropolitan Opera, introduces you to the art of caring for professional singers. What are the idiosyncrasies of providing care to this select population, who must be doggedly devoted to preserving strong health and maintaining good overall occupational status, most specifically those breathtaking voices? Host Dr. Michael Greenberg talks with Dr. Jahn about the delicate balance of prescribing steroids to elite vocalists, their exposure to alternative medicines and belief systems, as well as the role of placebos in mollifying superstition among high-level performers.
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