Dancers’ Reflections on Their Healthcare Experiences:
Perspectives from Australia and the USA
A dissertation presented to
the faculty of
the Graduate College of Ohio University
In partial fulfillment
of the requirements for the degree
Doctorate of Philosophy
Jill Descoteaux
August 2018
© 2018 Jill Descoteaux. All Rights Reserved 2
This dissertation titled
Dancers’ Reflections on Their Healthcare Experiences:
Perspectives from Australia and the USA
by
JILL DESCOTEAUX
Has been approved for
the Individualized Interdisciplinary Program
and the Graduate College by
Christine Suniti Bhat
Professor of Counseling and Higher Education
David Koonce
Interim Dean, Graduate College 3
Abstract
DESCOTEAUX, JILL, Ph.D, August 2018, Individualized Interdisciplinary Program
Dancers’ Reflections on Their Healthcare Experiences: Perspectives from Australia and the USA
Director of Dissertation: Christine Suniti Bhat
In the field of dance medicine and science, there is limited literature addressing dancers’ access to healthcare. Between 2007 and 2009, the journal Medical Problems of
Performing Artists published three articles evaluating the current status of performing arts medicine in three countries; Cuba (2007), Australia (2008), and the United States
(2009). American physician and researcher Mary Air identifies that “in many countries…dancers are largely disconnected from medical resources readily available to other professional athletes due to low income, tenuous job stability, lack of adequate health insurance, poor Workers’ Compensation, and underdeveloped networking systems between dancer and medical institutions” (Air, 2009, p. 42).
The research that forms the basis of this abstract (presentation) directly addresses the gap in research on dancers and healthcare. It has implications for the health and wellbeing of professional dancers, both freelance and companied, throughout their careers and life. Through a narrative qualitative lens, the purpose is to describe and compare American and Australian dancers’ experiences with healthcare. Twenty self- identifying professional dancers (10 in the United States and 10 in Australia) participated in semi-structured interviews reflecting on their experiences with healthcare. Their narratives address topics such as injury, access, self-care, mental-health, pregnancy, and insurance. Data collection took place during August of 2016 through August of 2017. 4
After member-checking and participant-feedback to validate the accuracy of narratives, content analysis of themes was conducted and is ongoing. Emergent themes included: 1.
“knowledge of body”, 2. “complementary and alternative medicine”, and 3. “receiving dance-specific care”. Implications for healthcare professionals include growing a dance- specific network of different kinds of practitioners and working towards an integrated care model.
5
Dedication
There’s nothing we can’t do if we work hard, never sleep,
and shirk all other responsibilities in our lives.
-Leslie Knope
Parks and Recreation; S4, E10 “Citizen Knope”
6
Acknowledgements
This project would not have been possible without the help of many groups and individuals. First, an enormous thank you to my advisor, Dr. Christine Bhat who has supported me through various semesters, states, and hemispheres - I am so very lucky to have a mental health counselor as an advisor. I’d also like to express great thanks to the committee: Dr. Claire Hiller for being my Australian advisor and counsel while overseas,
Dr. Janet Simon for her continued support, Dr. Peter Mather who guided the methodological intricacies of this project, and finally Dr. Tom Davis who first encouraged me to start this endeavor.
Moreover, thank you to Dr. Amy Vassallo and Dr. Evangelos Pappas for being a part of my Australian research support team. Big thanks to Dorothy Carrien for transcribing each interview and for the morning office chats that I miss. Thank you to
Ohio University; for supporting my research travels through the Student Enhancement
Award and the Patton College’s Graduate Research Fund, without my work would have been impossible. Moreover, a huge thank you to my good friend, Kelli Brazier, for agreeing to come into this project as my editor – I treasured our Facetime/Google
Doc/Catch-up nights.
Thank you to the family who have supported me like friends and to the friends who supported me like family. A special thank you to my mother whose loving nature and work ethic always inspires me. To my loving partner Kevin Sweet, for his monumental support and never-wavering belief in my ability to accomplish this task, thank you. An earnest appreciation for Shane Wiechnik, whose digital support from across the globe has been the secret weapon of my life. 7
And finally, it goes without saying that the words and experiences lived and relayed by the dancers that I have met have been instrumental. I began this work being inspired by dancers and I complete it still inspired.
Merde
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Table of Contents
Page
Abstract ...... 3 Dedication ...... 5 Acknowledgements ...... 6 Table of Contents ...... 8 Page ...... 8 List of Tables ...... 13 List of Figures ...... 14 Page ...... 14 Chapter One: Introduction ...... 15 Dancers ...... 15 International Dancer Healthcare Perspectives ...... 18 Dancer Healthcare Access ...... 18 Statement of the Problem and Rationale ...... 20 Research Questions ...... 21 Significance of Study ...... 21 Definitions ...... 22 Chapter Two: Review of the Literature ...... 23 Introduction ...... 23 Being a Dancer ...... 23 Physical and psychological burdens of dance...... 26 Dancers’ salary...... 28 Dancers’ healthcare...... 30 International perspectives...... 32 Public health services...... 34 Healthcare Policy ...... 36 History of United States Healthcare ...... 37 Current affairs in the United States...... 40 History of Australian Healthcare ...... 41 Current affairs in Australia...... 43 Comparing Healthcare Systems...... 44 Elements of Healthcare Delivery ...... 46 Integrated care...... 46 9
Complementary and alternative medical practices...... 47 Conclusion ...... 49 The Interview Questions ...... 50 Part one...... 51 Injury...... 51 Pregnancy...... 52 Part two...... 53 Part three...... 54 Chapter Three: Methodology ...... 55 Research Design ...... 55 Narrative inquiry...... 55 Researcher’s lens...... 56 Data Collection ...... 57 Participants...... 57 Selection of participants...... 58 Procedure...... 60 The pre-interview survey...... 62 The interview ...... 63 Validation strategy...... 64 Data Analysis...... 65 Procedure...... 65 Computer program...... 66 Validation Strategy ...... 66 Visualization of Analysis ...... 68 Chapter Four: Interview Summaries ...... 69 Introduction ...... 69 Vivian ...... 71 Nora...... 76 Fern ...... 80 Sam ...... 86 Jade ...... 92 Zoe ...... 96 Olivia ...... 101 Benjamin ...... 106 Coral ...... 109 Quinn ...... 113 Piper ...... 118 10
Alynn ...... 123 Harper...... 126 Una ...... 131 Gwen ...... 135 Liam ...... 138 Emerson...... 142 Yasmin ...... 145 Kat ...... 151 Ida ...... 155 Chapter Five: Results ...... 158 Introduction ...... 158 Results of Pre-Interview Survey ...... 159 Americans and Health Insurance ...... 161 Mindfulness of resource...... 162 The Patient Protection and Affordable Care Act...... 165 Australians and Health Insurance ...... 167 Private and public cover ...... 169 Freelance and company...... 172 American Dancers Access to Healthcare ...... 174 Seeking healthcare...... 174 Barriers encountered...... 175 Costs...... 176 Insurance coverage and referral...... 177 Within dance factors and scheduling ...... 179 Facilitating factors...... 180 Australian Dancers’ Access to Healthcare ...... 184 Seeking healthcare...... 185 Barriers encountered...... 186 Isolated circumstances...... 186 Within dance factors...... 187 Facilitating factors...... 188 American Dancers’ Reflections on Care ...... 190 Negative experiences...... 190 Positive experiences...... 192 Communication with healthcare professionals...... 194 Australian Dancers’ Reflections on Care ...... 196 Negative experiences...... 197 Positive experiences...... 198 Communication with healthcare professionals...... 201 11
Complementary and Alternative Medicine ...... 202 American Dancers and CAM...... 203 Australian Dancers and CAM...... 205 Managing Mental Health...... 207 Receiving Dance Specific Care ...... 210 American dance-specific care...... 211 Australian dance-specific care...... 214 Knowledge of Body ...... 216 American dancer knowledge...... 216 Australian dancer knowledge...... 219 Comparative Results ...... 222 Unique qualities...... 223 Similarities...... 224 Dancers and Pregnancy ...... 225 Chapter Six: Discussion and Implications ...... 229 Introduction ...... 229 Overview of the Study ...... 229 Universal and market-driven healthcare...... 230 Post-Patient Protection and Affordable Care Act...... 234 Companied and freelance...... 235 Dance-specific care...... 237 Patient education...... 238 Non-conventional healthcare...... 240 General Implications ...... 241 Implications for Healthcare Professionals ...... 242 Limitations ...... 246 Future Research ...... 247 Conclusion ...... 248 References ...... 249 Appendix A: Institutional Review Board Approvals ...... 261 Appendix B: Pre-interview Survey ...... 262 Appendix C: Interview Guide ...... 265 Appendix D: Brief Summary of Dancers ...... 267 American Dancers...... 267 Vivian...... 267 Nora...... 267 Fern...... 267 Sam...... 268 12
Jade...... 268 Zoe...... 269 Olivia...... 269 Benjamin...... 269 Coral...... 270 Quinn...... 270 Australian Dancers ...... 270 Piper...... 270 Alynn...... 271 Harper...... 271 Una...... 272 Gwen...... 272 Liam...... 272 Emerson...... 273 Yasmin ...... 273 Kat...... 274 Ida...... 274 Appendix E: Two Example Transcripts ...... 275 American Transcript: Zoe ...... 275 Australian Transcript: Harper ...... 276 Appendix F: Codebook ...... 279 Appendix G: Tables and Figures ...... 282
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List of Tables
Page
Table 1 Participants per Interview Date……………………………………………….....70
Table 2 Comparison Elements Between the United States and Australia……………...283
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List of Figures
Page
Figure 1 Visualization of Analysis………………………………………………………68
Figure 2 Current Expenditure on Health, Per Capita, US dollar……………………….282
Figure 3 Results of Professional Dancer Self-Identifying Question……………………282
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Chapter One: Introduction
Professional dancers are both artist and medium in the art of dance. The body, the dancer’s facility, is the entity that facilitates learning, training, healing, and performance for the dancer. As in all art forms, boundaries are meant to be expanded and experimented with. In dance, physical limits are pushed and dancers are left balancing their physical abilities with the artistry. Dancers often feel different from non-dancing peers; this can be attributed to the daily classes, heightened attention to the body, specialized dialect, and the isolated social milieu that is exclusive to dance (Sandham &
Kicol, 2015, p. 17). This difference in culture and physicality between dancers and non- dancers has encouraged, over the past several decades, the development of specialized attention to dancers from medical and psychological perspectives (Bronner, Ojofeitimi, &
Mayers, 2006; Côté-Laurence, 2004; Noh, Morris, & Andersen, 2005). The following research examined dancers as patients and consumers of healthcare.
The definition of a professional dancer is incredibly broad, varies greatly and may be based on monetary earnings, time, identity, history, training or a combination of these things. For the purpose of clarity, I refer to all kinds of self-identified professional dancers whose work aims towards the creation of art and expression and excludes recreational or erotic dance activity. In dance medicine and science literature, the professional ballet dancer, and secondary, the professional modern dancer, are often the most represented in the research.
Dancers
Mothers are often a driving force for young girls to begin ballet, and once a passion develops, dance can become a romantic, fantasy career which requires further 16 dedication and sacrifice (Sandham & Kicol, 2015). Possessing talent in dance, or developing it, is a multidisciplinary effort as young dancers strive to improve their physical and technical abilities, psychological fit, and artistry (I. J. Aujla, Nordin-Bates,
Redding, & Jobbins, 2014). The practice of dance isn’t without set-backs; different studies have shown an injury rate between 42% and 96% of young ballet and modern dancers (Krasnow, Mainwaring, & Kerr, 1999; Steinberg et al., 2011, 2013).
Aspects of dance culture normalize pain and injury, place the performance at a higher priority than the performer, and foster peer-to-peer competition influence the development of the dancer (Wainwright, 2005). Moreover, dancers often begin their career in youth and experience premature physical breakdown due to the increasingly acrobatic demands of contemporary repertoire, eventually leading to their young
(compared to societal norms) retirement (Leach, 1997). The competitive and physical- aesthetic aspects of dance culture often support maladaptive psychological development that can often predispose dancers to over-salient identification with the dancer role and career immaturity (Aalten, 2005; Golding, 2012).
The psychological and physical burdens of dance are weighed against its personal and artistic benefits. As dance training increases and becomes more consuming, the dancing body becomes “a piece of consequential equipment, and its owner is always putting it on the line” (Wainwright, 2005, p. 52). Additionally, as governmental and institutional budgets fluctuate, full year contracts are more difficult to find in North
America and Australia leaving dancers searching across states and countries to find more short-term contracts; the instability of which may encourage the average age of dancer retirement to decrease from late-thirties to late-twenties (Leach, 1997, p. 36). 17
Retirement can also be motivated by the high injury incidence rate of dancers.
Dance injury incidence rates in ballet have been recorded as low as 37.1% over 10 months to 76% over the course of a year; the lower extremity tends to be the subject of the majority of injuries sustained (Echegoyen, Acuña, & Rodríguez, 2010; Ekegren,
Quested, & Brodrick, 2014, p. 272; Noh et al., 2005, p. 84). Dance injuries are typically more chronic in nature, as they will build over a career, striking down a dancer just in time for performance (Bronner, Ojofeitimi, & Rose, 2003b). Dance injury research is a primary focus of the Journal of Dance Medicine and Science.
The largest association for dancer health and wellbeing in the world is the
International Association of Dance Medicine and Science (IADMS). The IADMS mission statement is to “enhance the health, well-being, training, and performance of dancers by cultivating educational, medical, and scientific excellence” (IADMS, 2018).
Established in 1997, their affiliated journal, the Journal of Dance Medicine and Science, has gone on to publish research from numerous countries including the United States, the
United Kingdom, Australia, Ireland, and Canada. Several countries have their own national organizations that advocate for dancers’ health and wellbeing such as the
Australian Society for Performing Arts Healthcare. In the United States that organization is the Association for Performing Arts Medicine (PAMA) as well as the Dancer Task
Force under DanceUSA. The domain of PAMA includes actors and musicians in their patient population and also publishes the journal entitled Medical Problems of
Performing Artists.
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International Dancer Healthcare Perspectives
In the field of dance medicine and science, there is a growing pocket of literature addressing dancers and healthcare, specifically dancers access to healthcare. Medical
Problems of Performing Artists published three articles, between the years 2007 and
2009, providing a national perspective on performing artist healthcare from the United
States, Cuba, and Australia. Each country’s healthcare is laced with history, politics, and morals that ensure that “one-size-fits-all” would not work due to the deep cultural expectations of each country. Furthermore, this literature included practitioners’ wisdom about what dancers are seeking from their healthcare professionals. The topic of dancers’ access to, perception of, and interaction with healthcare is also becoming visible in the collection of dance research. In a recent presentation, student researcher Stephanie
Alimena, presented recent work done with trainee and professional modern and ballet dancers in France. This work showed that professional dancers were more likely to seek care from a physician as a first choice while student dancers consulted their dance professors first (Alimena & Air, 2015). Overall, addressing access as a foundational concept to dancer healthcare is necessary because without access, a specialization in caring for dancers is moot.
Dancer Healthcare Access
A primary barrier to healthcare access in the United States is financial ability; health insurance is a way for healthcare consumers to manage the costs of medical treatment. For dancers, their vocation is known to have a typically low income, temperamental job security, poor worker’s compensation, and under-developed network of dance-knowledgeable clinicians; these factors underline how dancers lack financial 19 support via insurance in a time of injury or illness (Air, 2013). In a review of dancers in
San Francisco, just over half of professionally employed dancers (N=292) were offered private health insurance while under half of the same sample were covered by Workers
Compensation (WC) (Requa & Garrick, 2005). Furthermore, in an epidemiological review of dance injury and management, 69% of professional modern dancers sampled acquired injuries while dancing and WC covered 5% of these claims (Bronner et al.,
2003b). For the extraordinarily taxing profession that dance is, healthcare access is a necessity to manage the high prevalence of injury and psychological issues that arise from participation. Nonetheless, as demonstrated in the San Francisco study, the percentage of insured dancers appears low in relation to the level of physical demand of the profession.
These most recent publications reporting on the subject of dancers’ health insurance have been published in the United States, participants were solely professional companies, and were published before the Patient Protection and Affordable Care Act was written into law in 2010. A likely reason these reports are centered within the United
States is because alternative countries with a developed dance medicine and science output (United Kingdom, The Netherlands, Australia) each have a universal healthcare system so analyzing health insurance distribution is moot (Air, 2009a; Hadok, 2008).
Three studies of professional U.S. companies exist which analyze the insurance coverage to the dancers and cost to the companies, these companies are: Alvin Ailey (New York),
Boston Ballet (Massachusetts), and 28 companies in the Bay Area (California) (Bronner,
Ojofeitimi, & Rose, 2003a; Requa & Garrick, 2005; Solomon, Solomon, Micheli, &
McGray, 1999). Methods of analysis included retrospective records review, cross- 20 sectional survey of dance companies, and a prospective 5-year intervention study in which comprehensive management program was applied after 2 years (Bronner et al.,
2003a; Requa & Garrick, 2005; Solomon et al., 1999). These individual cities and companies have strengths and weaknesses in how they manage dancer healthcare needs and furthermore, previous research has not compared dancers’ medical insurance between cities or countries.
Statement of the Problem and Rationale
As dancers throw themselves into their art form, their strict dedication is often under-supported through healthcare. In the United States, the historical approach to privatized healthcare disproportionately harms persons lacking job stability and with lower-incomes such as dancers (Manchester, 2009). In comparison, Australia, a country with universal healthcare for its citizens has published limited accounts of dancers access to healthcare and moreover of what has been written, hints of an unorganized network of specialists for dancers to seek out (Hadok, 2008). The purpose of this study was to understand, explore, and compare a small sample of American and Australian dancers’ experiences of healthcare.
This information contributes to the knowledge of, and advocate for, dancers’ experiences and access to healthcare. The comparative element of this research aimed to critique and provide suggestions, from the dancers’ point of view, for both countries’ delivery of healthcare. At the least, this research is a novel attempt to add the dancers’ voice to the clinician- and research-dominated voices in dance medicine and science research. Overall, I aimed to better understand dancers’ perception and satisfaction of 21 their healthcare experiences in two countries that have different healthcare models – the
United States and Australia.
Research Questions
• How do dancers in the United States experience their healthcare including
access and satisfaction?
• How do dancers in Australia experience their healthcare including access
and satisfaction?
• What aspects are unique or similar between American and Australian
dancers’ experiences and perceptions of healthcare?
• What are the experiences with healthcare for dancers who have lived
through a transition (pregnancy and injury)?
Significance of Study
I combined elements from several disciplines (public health, counseling, sports medicine, and performing arts) to answer the research questions, fulfilling a partial requirement of my interdisciplinary doctoral degree. I aimed to create a work of advocacy on behalf of dancers, specifically from underrepresented genres and non-companied dancers. By using the narrative approach, this work gave participants voice in the existing dance healthcare research that adds a certain depth, humanistic perspective, and a practical insight for future research to build from. The information created through interview methods informs future directions and practical needs of dancer healthcare.
Furthermore, this research is part of an emerging sector of dance medicine literature that takes a qualitative approach to the physical and psychological problems of dance. For these reasons, this work is novel in its approach and subject compared to current 22 dominant trends in dance medicine literature. Adding dancer’s voices to the literature offers a greater complexity and depth than what is currently reflected in the healthcare and dance research.
Definitions
American: a participant who dances in the United States of America, as apposed
dancers in the 43 other countries within North and South America.
Alternative and complementary practitioner: a professional who is trained in
medical treatments that are considered outside of customary or a ‘Western’ model
of healthcare.
Dance-specific: the quality of a healthcare professional that demonstrates a
knowledge or understanding of the demands of dance (either physical or mental).
The professional should use appropriate communication (dance terminology and
relevant anatomy) and select treatment techniques specific to the dancer's
rehabilitation needs.
Dance-knowledgeable: used for professionals who don’t market themselves or
are not identified as dance-specific but are knowledgeable about dance medicine.
Healthcare professional: a medical physician or allied health professional such
as a physical therapist, athletic trainer, or nutritionist.
Mental health professional: a psychiatrist, psychologist, licensed professional
counselor, licensed social worker.
Somatic practitioner: professionals who use Pilate’s, Feldenkrais Method, or
Alexander technique.
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Chapter Two: Review of the Literature
Introduction
This work examined how healthcare interacts with dancers. In another light, it is a commentary of the lived experiences of citizens of a certain profession functioning under a nation’s chosen healthcare system. The purpose of exploring these two outlooks
(Australian dancers and American dancers) through stories and qualitative analysis is to uncover the practical insights that dancers share through their experiences with healthcare
(Clandinin & Connelly, 2000). These insights have been compiled with the intent to share them with healthcare professionals who work with dancers and have professional investment in the well-being of dancers. The embedded comparative element, serves to provide reflective context to each groups stories.
Throughout history, dancing has been a form of communication, expression, ritual, and entertainment. It is in the past four to five decades, with the acceptance and popularization of sport and exercise science, that examining dancers as patients has become a field of study in its own right. This review encompasses a description of dancers from the literature that describes their lifestyle and burdens. To address the location element, a brief review of national health systems and healthcare delivery methods is provided about the American and Australian systems. This chapter ends with a detailed description of the literature that supported the interview guide used in all dancer interviews.
Being a Dancer
Katinka Tuisku frames the workload of an artist perfectly writing “artists are known for performing autonomous, creative, intensive, and personal work that is 24 dependent on public recognition and uncertain funding” (Tuisku, Houni, Seppänen, &
Virtanen, 2016, p. 104). Keeping these traits in mind, placing the concept of a dancer between the dichotomy of being an artist or an athlete is debated (Kaufam, 2015). One side may argue that for all the expression, storytelling, and creativity that is a foundation of dance artistry, that “ballet is an artist’s job, not an athlete’s job” (Wainwright, 2005, p.
55). However, dance being recognized as an athletic endeavor has come with increased sports medical attention over the past 30 years that was previously reserved for sport athletes. This attention translates into dance-specific clinics, funding, professional organizations, and a growing collection of medical professionals taking special interest in dancers as patients. Whether a dancer was more artistic-athlete or athletic-artist may be ever dependent on each new choreography, context, or perspective.
The framework of a dancers’ professional practice has many avenues of variability such as company size, the dancers’ roles and responsibilities to the creation of the work, genre, repertoire, hours, and employment status. Many variables create the utmost flexibility in a dancer's career choices. These same choices are sometimes the responsibility of the dancer, sometimes serendipitous, and sometimes luck. Many artists, visual or performing, are self-employed individuals working as a freelance contractor either solo or in collectives. Performing arts are primarily collaborative in nature and dancers are often freelance contractors in small to medium companies or contracted into higher-budget medium to large companies such as LINES Dance Company or
Nederlands Dans Theatre. Roles or statuses under which dancers may be categorized are:
Companied, Freelance, Teacher, Somatic-practitioner, Company owner, and Retired. A dancer may fulfill multiple of these roles at a given time. 25
Research has shown that dancers demonstrate a unique group identity and culture which differs from their non-dancing peers (Golding, 2012; Wainwright, 2005).
Beginning in childhood, young dancers begin to form dance-related social networks, advance in training techniques, learn French terms for balletic steps, and explore genres.
Each aspect increases the salience of the dancer identity. The process of developing dance technique is accomplished through rigorous goal-setting, dedication, and motivation from advancement (Aalten, 2005; Greben, 2002; Leach, 1997). Though interviewing professional ballet dancers, Aalten found a description of a “true dancer” as someone with complete dedication who “does not even want anything else” (Aalten,
2005, p. 8). A psychologist reflecting on their over 160 dancer-clients described dancers as “intelligent, multi-talented, and highly motivated…accustomed to being instructed, directed, corrected, and are goal-directed” (Greben, 2002, p. 15). Other mental traits of the typical dancer may include a knowledge of anatomy from advanced training and experience with injury (Kotler, Lynch, Cushman, Hu, & Garner, 2017) and an awareness of the inevitably of retirement in the fourth and fifth decades of life (Roncaglia, 2006).
Each of these aspects encompasses the mental makeup of a dancer.
The dancer identity is further encompassed in physical development; dance cultures’ affinity for slim dancers with a low-body weight is infamously known. In addition to thinness, dancers are situated to develop excellent strength, flexibility, and agility dependent on their training, chosen genre, and level of athleticism of their repertoire. Wainwright notes that “the vocational calling to dance is so overwhelming that their balletic body is their identity” (Wainwright, 2005, p. 49). The negative implications of the body as facility is that “dancers base a good deal of their sense of 26 well-being on both their physical ability and their physical attractiveness” (Greben, 2002, p. 15). Most of the research which that these qualities are extracted from are with professional ballet or modern dancers; little is known about potential differences in other dance genres. However, there is a common thread throughout available literature of dancers’ identity which is summed up well in the Aalten article that elite dancers have a
“the chosen people mystique” ascribed to their ability of performing physical feats that non-dancers cannot (Aalten, 2005, p. 9).
Physical and psychological burdens of dance. A majority of dance injury epidemiological data exists for two genres: modern/contemporary dance and ballet.
Moreover, the literature’s agreement of the term “injury” varies making synthesis difficult; a 2009 mixed methods study, the majority of dancers considered an injury something that stopped them from participating in dance or moving normally (Thomas &
Tarr, 2009, p. 56). The prevalence of dance injury in previous retrospective and prospective cohort research has been reported to be between 37.1% to 82% (Noh et al.,
2005; Shah, Weiss, & Burchette, 2012). Most often dancers sustain injury affecting their ligaments (Echegoyen et al., 2010; Ekegren et al., 2014; Ojofeitimi & Bronner, 2011) with muscle strains being the second most injured tissue in the dancer's body (Echegoyen et al., 2010). Depending on the research, the majority of issues are categorized as
‘overuse’ or as ‘acute,’ though these seems to alternate per study (Echegoyen et al., 2010;
Ekegren et al., 2014; Ojofeitimi & Bronner, 2011). There are many additional factors such as age, gender, level, company-status, genre, reporting method, and touring-status that each play a part in teasing out certain dance injury rates (Caine, Goodwin, Caine, & 27
Bergeron, 2015; Hopper et al., 2014; Leanderson et al., 2011; Liederbach, Dilgen, &
Rose, 2008).
The process of injury is so prevalent in the dancer population, that “living and dancing with painful injuries is common [to the extent] that some accept it as a sign of professional commitment” (Rip, Fortin, & Vallerand, 2006, p. 14). In their research investigating the relationship between passion and injury, Rip et al. found that an obsessive passion for dance was found to be associated with suffering from chronic injuries, continuing to dance when injured, and pride preventing dancers from seeking appropriate medical treatment (Rip et al., 2006, p. 18). The event of becoming injured can be an additional stressor to the dancer, that it may alter the dancer’s relationship with their practice and identity during and after the physical rehabilitation. A qualitative study of 26 ballet dancers found that post-injury ballet dancer behaviors included being “more careful when dancing, consciously trying to use better technique, modifying exercises, stretching more to avoid reinjury, and being more aware of body” (Macchi & Crossman,
1996, p. 229). Most recently, researchers found that a majority of injured dancers perceived that being injured increased their knowledge of their anatomy but no significant correlation was found between injury history and actual knowledge of anatomy (Kotler et al., 2017, p. 79).
In the past ten years of research, several psychological descriptions / illnesses of dancers have stood out in the literature. These are eating disorders, anxiety, and perfectionism. Eating disorders are the most infamous mental illness tied to professional dance. The literature reports prevalence as low as .9% of reported anorexia nervosa to as high as 73.1% of dancers with a disordered eating pattern (Herbrich, Pfeiffer, Lehmkuhl, 28
& Schneider, 2011; Ravaldi et al., 2006). While perfectionism may be divided into an adaptive and maladaptive category, the literature demonstrates that between 20% and
40% of dancers have perfectionist tendencies (Cumming & Duda, 2012; Eusanio,
Thomson, & Jaque, 2014; S. M. Nordin-Bates, Cumming, Aujla, & Redding, 2014).
Finally, anxiety in dancers has been studied through qualitative interviews and through survey-based research. Results show that dancers have a myriad of dance-related stresses including leanness, achievement, developing professional relationships, times of change, and performance anxiety (I. Aujla & Farrer, 2015; Noh et al., 2005; Walker & Nordin-
Bates, 2010).
Dancers’ salary. As artists, dancers’ work may include “irregular work, frequently changing workplaces, inappropriate work spaces, marginalization, hard competition, and uncertainty of income” according to Finnish researchers (Tuisku et al.,
2016, p. 105). Freelance dancers rarely have a 52-week contract and are subjected to performance seasons. Greben notes his dancer clients “rarely earn a comfortable living” and have “limited sources of financial security” (Greben, 2002, p. 16). They continued writing that once a dancer retires “what little financial security the dancer had while working turns into serious financial need once the career has ended” (Greben, 2002, p.
17). Dr. Linda Hamilton reinforces this sentiment in her book Advice for Dancers; having written that dancers often require a steady job to support their dancing career, also known as moonlighting (Hamilton, 1998). Not unusual in the arts, the dancer may find complimentary work to allow them to practice their art in the off-hours. She posits that dancers are well suited to work in the somatic therapies, teaching, or other physically- inclined professions such as personal trainers or leading fitness classes (Hamilton, 1998). 29
National information detailing the breakdown of dancers’ incomes at various levels is unavailable, leaving us to look at the “average income” and several casual recounts of dancer-clients claims. According to the U.S. Bureau of Labor Statistics, the median hourly wage for an American dancer increased from $14.31 in 2014 to $16.85 in
2016 (U.S. Bureau of Labor Statistics, 2015, 2018). Assuming a dancer may work 40- hours a week, which is unlikely for a freelance dancer, we can estimate a full-time dancer with an hourly wage of 16.85 would have an annual gross income of approximately
35,000 American dollars. However, with the variance of work settings in dance and differences in living costs in each state/county/town, it is unreliable to make sweeping statements about an average salary at all.
Over the past 30 years in Australia, Macquarie University, in conjunction with the
Australia Council for the Arts, have provided information about “the economic circumstances of professional artistic practice across all major art forms apart from film”
(Throsby & Zednik, 2010, p. 7). The most recent publication in 2010, reported that artists
(not specifically dancers) earned an average of $41,200 AUD in the 2007/2008 financial year with the median income being 35,900 of the same reporting period (Throsby &
Zednik, 2010, p. 47). Adjusted with the 2008 AUD to USD July conversion rate, and secondly adjusted for the USD inflation rate between 2008 and 2017, $41,200 AUD in
2008 would be worth approximately $44,732 USD in 2007 ($9,732 USD more than the calculated American average dancer salary). Comparing the data sources, the Australian study appears more reliable in that it specifically was created to capture the nuance surrounding being an artist while the United States data source, from the U.S. Bureau of
Labor Statistics, is more generalized. 30
Dancers’ healthcare. Because pain-acceptance has been cultivated in dancer populations, dancers have an inclination to self-diagnose, self-treat, and continue dancing
(R. Anderson & Hanrahan, 2008; S. Nordin-Bates et al., 2011). In a study of professional
European ballet dancers, a significant positive correlation was found between ‘time away being injured’ and ‘increased psychological stress, which was related to the fear of losing a company position due to missed rehearsals and performances (Adam, Brassington,
Steiner, & Matheson, 2004). A 2008 cross-sectional analysis found that dancers cognitively appraise performance-related pain and injury-related pain in such an indistinguishable manner that it may place the dancer at risk of ignoring pain that is indicative of an oncoming injury (Ruth Anderson & Hanrahan, 2008). A mixed-method
British study found that dancers with “persistent low-grade pain that did not impinge on the ability to dance…did not seem to be equated with an injury” (Thomas & Tarr, 2009, p. 57). As such, the lack of pain and injury differentiation, combined with a "show must go on" mentality, may lead a dancer to not seek attention for their pain or injuries.
Krasnow, Kerr, and Mainwaring proposed several practical and psychological barriers to seeking medical attention for injuries in a dance population these were;
(practical) financial considerations, accessibility to appropriate medical professionals, time, (psychological) dancers’ perceptions of the medical field, social culture of the dance world, overwhelming fear of loss of employment, and perceived personal change
(Krasnow, Kerr, & Mainwaring, 1994). In regard to health insurance in the United States,
Alimena and Air screened 37 metropolitan dancers and found that the majority of dancers did have some form of health insurance (62.2%) leaving 37.8% of dancers hypothetically uninsured; this is more than three times the national average of uninsured persons. 31
(Alimena, Air, Gribbin, & Manejias, 2016, p. 97). In a study by Lai, Krasnow and
Thomas in 2008, surveys were distributed to dance practitioners and dancers to self- report on healthcare related constructs such as communication, perception, understanding, and compliance. In their sample of 35 professional medical practitioners,
22% had attended a dance-medicine orientated conference and 32% had read dance medicine literature (Lai, Krasnow, & Thomas, 2008, p. 48). There was also a positive correlation between reading dance literature and dance patient volume; the practitioners who read more dance literature were able to ask more poignant questions such as that of technical habits. Lai’s main finding included evidence that the practitioners who observed dance more frequently (20% had never observed dance) also reported more communication occurring between themselves and their dancer patients. Mirrored to this, the dancers surveyed (N = 202) indicated that it was more important to them that their medical practitioner speak with other medical practitioners involved in the same injury management than speaking with the dancers’ choreographer or dance instructor (Lai et al., 2008, p. 49). A report from France and Monaco explored aspects of trust, satisfaction, and confidence in the dancer-physician relationship finding that as “few as 17% of dancers will seek care from a medical doctor when injured” (Alimena & Air, 2016, p.
166) Moreover to their purpose, the researchers found that dancers trusted physical therapists more than they trusted physicians, and moreover, that student dancers trusted physicians less and were less confident that physicians could diagnosis a dance related injury compared to professional dancers (Alimena & Air, 2016, p. 169). The authors question whether appointment duration may be correlated with trust since dancers may 32 expect to see a physical therapist for one hour compared to 10-minute physician appointments.
International perspectives. Between 2007 and 2009, the journal Medical
Problems of Performing Artists published three articles evaluating the current status of performing arts medicine in three countries; Cuba (2007), Australia (2008), and the
United States (2009). Each article was written by a different author, from the first-person perspective, and was individually framed. The Cuban article explored various performing arts companies as a part of a group trip to learn about the healthcare system and “Cuban approaches to artists’ health and safety” (Babin, 2007, p. 74). Cuba offers universal healthcare, has a strong focus on local polyclinics, and focuses on preventative healthcare according to the author’s experience. Cuba has a ratio of physicians to patients ranging from 175 patients per physician to 600 patients per physician dependent on the geographic location. Furthermore, Cuba’s access to medications and new equipment was shown to be limited which was demonstrated by their need to autoclave, sterilize, and reuse a majority of their equipment (Babin, 2007). Babin reflected that although the
Cuban healthcare delivery system was different to the United States, the demands of performing arts were the same with similar risk factors (hearing loss, musculoskeletal injury, and stage effect exposures) and injury rates (2007).
The Australian perspective was written by Dr. John Hadok, an Australian medical director and lecturer, about his attempt to “bring together healthcare workers with an interest in caring for performing artists” (Hadok, 2008). After outlining the importance of art in society, Hadok lays out seven challenges to achieving his aforementioned goal as well as eleven opportunities. Examples of the outlined barriers include: performing arts 33 medicine not fitting into government funding guidelines, the pockets of population separated by desert, and the disjointed network of specialists interested in treating performing artists. The primary opportunity that he suggests is that Australia was well positioned to design an ideal performing arts medicine network from its disjointed pieces by outlining possible educational opportunities, practice models, and goals to consider
(Hadok, 2008). Recently, Australian dance researcher Amy Vassallo published the first national study in Australia to incorporate both companied and freelance dancers; her findings suggested that freelance dancers often have less access to dance-specific healthcare professionals and that treatment is out-of-pocket rather than a benefit of employment (Vassallo, 2018).
The third article was published one year before the United States adopted the
Affordable Care Act. A unique aspect of United States healthcare pointed out in this article is that the United States is “the only country in the world that allows companies selling basic health insurance to make a profit” (Manchester, 2009, p. 155). The article states that performing artists in the United States are more likely to lack health insurance, but then notes that there are no national statistics on health insurance by occupation to support this claim quantitatively. The author highlights concerns of politics, morals, and history that all influence this difference between the United States and other countries’ healthcare systems. After reviewing each article, it is apparent that each country has both strengths and weaknesses and determining the variables of importance are critical when studying these healthcare systems. The importance of comparing countries’ healthcare systems as such is to understand in depth the contextual reality of a single country’s healthcare distribution. Moreover, comparison is useful to identify the elements of a 34 healthcare system that are working well and those that are harming both citizens and dancers.
Separate from this series, physician and dance-researcher Mary Air, has a body of work that explores dancer’s access to healthcare from an international perspective. She identifies that “in many countries, including the United States and Japan, dancers are largely disconnected from medical resources readily available to other professional athletes due to low income, tenuous job stability, lack of adequate health insurance, poor
Workers’ Compensation, and underdeveloped networking systems between dancer and medical institutions” (Air, 2009b, p. 42). Employing a descriptive survey design, Air found comparatively better access to healthcare for a sample of Dutch dancers than previously cited United States dance medicine research. Moreover, from this sample, dancers who sought out medical practitioners were satisfied with their treatment, and had positive interactions with their medical professional (Air, 2009b). An additional finding was dancers’ efficient use of physiotherapy prior to or in addition to seeking care from a physician. Air essayed that where it is difficult to institute governmental change, promoting the use of physical therapists, athletic training, and physiotherapy as supplemental care for medical treatment may be a means of overcoming barriers to access for dancers (Air, 2009b).
Public health services. Artists are hardly a homogenous group, however certain traits such as short-term job contracts and, consequently, fluctuating paychecks are a common reality for American dancers, this creates a logistically unfavorable situation for obtaining health insurance. In both the United States (varies state by state) and Australia
(Safe Work Australia Act of 2008), employers with a number of employees are lawfully 35 required to offer a form of coverage, often known as Work Cover or, more formally,
Workers’ Compensation. This type of insurance is purchased by the employer and is meant to cover any occupation-responsible injury or illness that occurs in its workers.
Concerning artists, it must remain in consideration that worker’s compensation can be difficult to file in cases of chronic pain, injury, or symptomology. For example, a violist whose forearm presents with progressive numbness during performance which cannot be traced to a single event may have difficulty claiming this numbness as work related
(Chimenti et al., 2013).
Artist friendly services that make buying healthcare more understandable and affordable are mostly in population dense cities such as New York, Los Angeles, and
Chicago. Organizations such as The Freelancer’s Union and Fractured Atlas operate to give artists more health insurance choices, such as buying group insurance rates and specialized healthcare plans. A 2006 article in American Artist magazine reported on a hospital in Brooklyn that initiated a program to exchange cultural services for healthcare credits (Grant, 2006). For every hour of hospital art classes taught, artists would receive
$4 of credit for future hospital services. Moreover, the Actor’s Fund is an advocacy organization for all professionals in the performing arts, one of their services is the
Artist’s Health Insurance Resource Center (AHIRC) (The Actors Fund, 2016). The
AHIRC provides services to help artists find affordable healthcare such as consultations, resources/web links, seminars, outreach programs, and being an advocate for legislative changes that support cheaper health insurance options (The Actors Fund, 2016).
36
Healthcare Policy
In 1798, president John Adams signed into law the “Act for Relief of Sick and
Disabled Seamen” which is the first time the United States federal government took responsibility over the fate of its citizens’ health through legislation (Emanuel, 2014, p.
14). National healthcare began for the Commonwealth of Australia in 1945, 44 years after its founding, with the “Hospital Benefits Tax” (Willis, Reynolds, & Keleher, 2016, p. 15). Before these historical legislative changes, these two nations did not demonstrate any governmental responsibility in its citizens’ health. Citizen health is an issue that the
United Nations (UN), made up of 193 member states, grapples with regularly. More specifically, in association with the United Nations is the World Health Organization
(WHO) which holds the goal “to build a better, healthier future for people all over the world (“World Health Organization,” 2018). In 2015 the United Nations proposed a
Sustainable Development Agenda which outlined 17 goals and overall agreed to the goal of “achiev[ing] universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” by the year 2030 (World Health Organization,
2015). Under the principle of universal health coverage, all citizens would have equitable access to health services. Put another way, “healthcare as a right” is determined by being a citizen of a nation that delivers universal healthcare and is one of 17 priorities the UN has set forth. In 2017, it was reported by the Organisation for Economic Development that 100% (24 million) of Australian citizens were covered by insurance and 90.9% (296 million) of American citizens were covered by insurance (Organisation for Economic
Development, 2017). 37
Comparative public policy academic, Dr. Carolyn Tuohy, postulated that “given health is central to the well-being of a nation, what role should the state play, and what role should the market play in providing healthcare?” (Tuohy, 1999, p. 3). This question eludes to why there is such a variety between countries being on a spectrum between a market model healthcare system and a universal healthcare system. Particularly in
Australia and the United States, there is a progressing debate about where to fall on this spectrum. Historically, these countries’ methods of managing public health came from two opposing sets of ideas; healthcare as right versus healthcare as personal responsibility, and more recently in the United States, healthcare as mandate. Healthcare as a personal responsibility can be defined as “you deserve the healthcare that you earn”
(Gluck, 2017). Tuohy argues that the movements that governments go through which develop or reform healthcare policy is the product of being in the right place, at the right time, with the right support (1999). Therefore, where a county falls on this spectrum may be “essentially accidental, a product of a specific time and particular circumstances”
(Tuohy, 1999; Willis et al., 2016, p. 49). Furthermore, the historical development of these healthcare systems alongside an awareness of the relevant philosophical underpinnings and national identities provides insight into understanding how each country arrived at its current method of healthcare delivery.
History of United States Healthcare
It is obvious when observing political discourse over the American healthcare system that it has become a large, multifaceted, complex problem. So complex that
Ezekiel J. Emanuel, author of the book Reinventing American Healthcare, retells the work of Senator Arlen Specter (R-Pennsylvania) whose staff in 1993, in opposition to the 38
Clinton healthcare reform ideas, created a graphic of the interconnections of the healthcare system which ended up looking “more like a computer circuit board with tangles of connections…than a logical structure” (Emanuel, 2014, p. 34). The stakeholders shaping the development of healthcare in the United States include policy makers in the government, activist groups, non-profit health organizations, physicians and nurses, lobbyist groups, hospitals, insurance companies, and patients. With so many interests in play, it’s not surprising that the political decision making is often fraught.
Health insurance “provide[s] financial protection from unanticipated illness episodes and is a mechanism for financing or pre-paying a variety of health benefits that are neither unexpected nor rare” (Patel, Caldwell, Song, & Wheeler, 2014, p. 398).
Beginning in the Dallas Texas school district in the 1920s, collecting insurance premiums in exchange for guaranteed medical (hospital) services was the idea of Dr. Justin Ford
Kimball. Two decades later, with the Stabilization Act of 1942, (a response to war pressures which forced employers to stabilize their wages to a fixed amount), healthcare has been tied to health insurance as a part of a remuneration package of full-time employment (Emanuel, 2014, p. 30). This legislation inspired a creative way for employers to increase take without increasing salary. This shift in insurance as part of employment remuneration saw the rise of insured Americans through the 1950s. This method places the responsibility of affording health insurance onto citizens and private industry. The primary cited problem with this method is that a remuneration package is typically offered to those with full-time employment in mid-to-large companies; this omits homemakers, part-time employees, freelancers, and small-companied workers.
When citizens cannot purchase healthcare services for themselves, this is market failure 39 and can be used as a reason to support government intervention (Willis et al., 2016, p.
18).
Large-scale, privatized health insurance in the United States originated in a pay- for-fee model of the Blue Cross and, the then separate, Blue Shield organizations. They were first organized during the Great Depression of 1929 as a measure to protect the financial welfare of physicians (Blue Shield) and hospitals (Blue Cross) against the increasing hospital fees and population of patients who were unable to afford their hospital fees (Emanuel, 2014). The federal government began offering health insurance with the invention of veteran’s benefits in 1930 (Emanuel, 2014). Moreover, programs such as the Childrens’ Health Insurance Program (CHIP), TRICARE (current military and military families), and the Department of Veterans’ Affairs are all public health insurance programs that the United States federal government manages. With private health insurance companies expanding in the mid-century, and a growing population, the demand for medical services increased. In the 1970s, Health Management Organizations
(HMO) developed into the subsequent need of “low-cost comprehensive care for a fixed annual fee to local communities” (Willis et al., 2016, p. 47).
In 1965, the United States saw the introduction of Medicare (a social insurance) and Medicaid (a means-tested insurance program); these two systems were designed to offset out-of-pocket healthcare costs for the elderly, low-income earners, and individuals with specific disabilities. As this system grew more corporatized and reliant on managed care practices, health reform policies began being proposed during the Clinton administration. The United States is the “only democratic nation with a significant uninsured population” (Willis et al., 2016, p. 49). 40
The Patient Protection and Affordable Care Act (PPACA) was signed into law in
March 2010 by then president Barack Obama after two years of drafts and proposals
(Human and Health Services, 2015). Most famously this bill enacted policies that supported provisions such as staying on parents’ health insurance until the age of 26, no barrier to insurance based on predisposing conditions, and no limits as to what can be paid out over the course of a lifetime. Some of the PPACA aims were to “increase the number of insured persons, control activates of health insurers, change Medicare payments, [increase] funding for primary care physician training, and manage hospital activity” (Willis et al., 2016, p. 48). In the year 2014, the health insurance marketplace opened and it became each United States citizens’ responsibility to purchase and maintain health insurance, lest they incur a tax-fine at the end of the year (Human and Health
Services, 2015). Known as the “individual mandate” this is by far the most contested provision and took effect in 2014. This is an example of a government policy pushing to offer universal healthcare through subsidies for low-income earners while doing so through a “healthcare as mandate” principle.
Current affairs in the United States. The United States healthcare has been in contention over the better part of a decade since the PPACA was signed into law in 2010.
Under the PPACA, a number of provisions are scheduled to “roll-out” each year until
2020 with the overarching goal to reduce the number of uninsured citizens in the United
States. United States Republicans campaigned in 2016 on a platform of “repeal and replace” of the PPACA with a heavily cited grievance on the individual mandate. During the campaign, their rhetoric commonly included such terms as “disastrous”, “nightmare”,
“horrible”, and “failing” when discussing reasons for repealing PPACA (A. B. C. News, 41
2017). These terms echoed the feelings of the American populace who “felt misrepresented by the enaction of Obamacare” (CNBC, 2017). The election resulted in a single party sweep with a Republican-majority Congress as well as a Republican
President. With such a sweep, the expectation was that repeal and replace legislation would move swiftly without the possibility of contestation from Congressional
Democrats. However, over the course of 2017, Senate Republicans and House
Republicans have both proposed bills that have failed to come to a vote or failed the vote by a very small margin. These attempts have been presented four times in the first eight months of the new presidential administration; these bills include: The House American
Healthcare Act (AHCA), the Senate Better Care Reconciliation Act, the short-lived
Senate “Skinny Repeal”, and the late-summer Senate Graham-Cassidy Healthcare Bill. It is important to acknowledge that at the time of the 2017 inauguration, PPACA was not fully rolled-out and was followed by four Republican attempts at healthcare reform over the first 8 months. This resulted in a heightened state of flux for American healthcare policy - a status that only contributed to the uncertainty that American’s had over the future of their healthcare system. Two ways the PPACA has been weakened was the shortening of the 2017 enrollment period for new PPACA marketplace customers and beginning in 2018, a new tax-law which was passed by Congress that eliminated the individual mandate provision of PPACA.
History of Australian Healthcare
Today’s Australian healthcare system is a “mix of public welfare and private market provision”, called a “mixed-model” of healthcare delivery (Willis et al., 2016, p.
3). Between the 1940s and 1980s, the Australian healthcare system underwent politically 42 charged changes swaying between government-funded and private health insurance (PHI) models. A major provision was the adoption of Medicare in 1984 which was followed by
PHI rates of enrollment dropping more than half which may be interpreted as “the public’s confidence that Medicare would provide a satisfactory level of health insurance for most people and is, to a certain extent, self-perpetuating” (Willis et al., 2016, p. 35).
Today, the public welfare portion of the Australian system is called Medicare and is partially funded by a 1.5% or 2.5% taxation of all citizens (based on income-level and whether or not the individual has purchased PHI); an extra 1% tax is applied to higher- income level earners if they do not purchase their own PHI coverage by the age of 30.
Opinions of the public health system varies regarding efficiency, quality and so forth. In defense of the public system, Australian oncologist and Fulbright scholar
Ranjana Srivastava writes:
Working in the public hospital system can seem like a Sisyphean task whether
you are an orderly or an oncologist. But we stay because we are sustained by a
fundamental belief that the true measure of a society is how it looks after its
weakest...The outside world regards the Australian healthcare system as a jewel in
our crown. It’s time we realised why (Srivastava, 2016).
Her statement demonstrates her high level of work and pride that comes with having a universal healthcare system.
In addition to the public system, Australia utilizes PHI as a supplementary coverage to the public healthcare system. Although, it is unique in that it “allows patients with PHI the option of being treated either publicly or privately in public hospitals”
(Seah, Cheong, & Anstey, 2013, p. 1). This began in 1997 as a government response to 43 declining private health insurance enrollment. The principle of community rating rejects discriminatory pricing of individuals based on health status, as allowed in the private market in the United States before PPACA (Willis et al., 2016, p. 30). This policy was enacted in 1997 as an effort to support PHI enrollment (Seah et al., 2013). All Australians may use the public medical services paid for by Medicare as well as purchase their own private health insurance.
This support of the PHI system is not without controversy fueled by the dual costs of reallocated public funds and the increasing revenue of PHI companies (Seah et al.,
2013, p. 2). Furthermore, supporting both PHI and national Medicare shifts the philosophical focus away from universalism and towards a mixed-model approach to healthcare – leaving citizens with a greater personal responsibility of their medical risk
(Willis et al., 2016, p. 32). Researchers in the Australian Health Review criticized the mixed-model in Australia by pointing out that certain policy loopholes in PHI subsidies allow insurers to avoid payment of their clients’ health bills when their client uses the public system (Seah et al., 2013). This creates an ethical resentment or even confusion of citizens when persons with PHI use public hospitals and their private insurance pays the lower, public, price rather than what that policy would typically pay out to a private hospital.
Current affairs in Australia. The current Australian healthcare system is mixed with a universal foundation, also known as the “public market,” which has been in effect since the 1980s. However, Australia’s government encourages its citizens to purchase private health insurance to offset the subsidies the government pays into national healthcare. In May of 2014, the Australian government, under the leadership of the 44
Abbott administration, proposed a 7-dollar co-payment for basic physician consultations for Medicare consumers (A.B.C. News, 2015). The Australian public met the proposed change with resistance. After nearly 10 months of debate with liberal party leaders, interest groups, and growing public dismay, the proposed co-payment was “dumped because there wasn’t enough support for it” (A.B.C. News, 2015).
Comparing Healthcare Systems
As an American researcher, concern over comparing healthcare policy systems comes from the “obvious successes of other national health systems in providing more with less” (McLaughlin & McLaughlin, 2018, p. 16). Cross-national comparison of healthcare allows researchers to track performance, highlight areas of strength and areas for improvement (Squires & Anderson, 2015); for a quick summary of the United States and Australia, see table 2.
It is well known that the United States has both a high percentage of uninsured citizens as well as paying the highest percentage national income on healthcare than other developed countries (Figure 2) (Schoen et al., 2007, p. 718). A 2006 study with a sample size of 8688 American and Canadian citizens found that United States citizens fared “one third less likely to have a regular physician, one fourth more likely to have unmet healthcare needs, and are more than twice as likely to forgo needed medicines” in comparison to the Canadian participants (Lasser, Himmelstein, & Woolhandler, 2006, p.
4). In a different study, both Canadian and American patients were more likely to not receive same-day access and to report long waits compared to Germany, the Netherlands,
New Zealand, Australia, and the United Kingdom (Schoen et al., 2007, p. 724). It is clear 45 that there are numerous quantitative data points that can be measured to compare healthcare policy systems.
Established in the 1960s, the Organisation for Economic Co-operation and
Development [OECD], a research group in which 34 member countries participate, aims to share and seek solutions to common problems (Organisation for Economic & Co- operation and Development, 2016). In 2017, they published that of all the OECD countries, Chile, Greece, Mexico, Poland, the Slovak Republic, and the United States were the countries that have not adapted a universal healthcare system (Organisation for
Economic Development, 2017). From the same report, the United States had the highest total healthcare spending per capita ($9,892) while Australia had the lowest healthcare spending per capita ($4,708) with data presented in USD (Squires & Anderson, 2015).
Comparing global indicators of health between the United States and Australia, the latter has a lower maternal mortality rate, lower obesity prevalence rate, and a longer life expectancy from birth (Central Intelligence Agency, 2016). However, it must be noted that Australia has a smaller population, smaller global-market, and smaller external debt.
A delimitation of this research was choosing a single comparative nation to the
United States. The free-market, also known as market-driven system, has been an attribute of the United States since the beginning of its history with health insurance.
Opposite of a free-market system would be universal healthcare; there are several countries of note that offer a form of universal healthcare such as France, Finland,
Sweden, and the United Kingdom. However, with the introduction of PPACA in the
United States, there was a palpable shift happening in the America. An initial consideration of this research was that the American dancer-participant would have been 46 subject to these legislative changes from the years 2010 to present. Therefore, Australia was chosen as the comparator country due to its similar shift in contemporary history.
Australia has offered universal healthcare since the 1970s, but since the Howard
Administration (Coalition) in the early 2000s, the Australian government has had an extra healthcare levy, encouraging the public to purchase private health insurance. Moreover, both countries have a prominent voice in the field of dance medicine. As the United
States administration under President Obama pushed for more healthcare initiatives to be funded and controlled by the federal government, the Australian federal government is pushing just the opposite way with the 2014 proposal of the public system co-payment.
Elements of Healthcare Delivery
This section describes two elements of healthcare delivery; integrated care and complementary and alternative healthcare practices. Both elements are
Integrated care. Integrated Care is the intentional collaboration between both a conventional practice and a complementary practice (National Center for Complementary and Integrative Health, 2011) or moreover, it can be the systematic coordination of general and behavioral healthcare (Substance Abuse and Mental Health Services
Administration, 2018). The World Health Organization describes Integrated Care System as, “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results, and provide value for money” (World Health Organization, 2008). Integrated care is an ideal approach for patients with both a general medical condition (diabetes, hypertension, obesity) and a behavioral health issue (substance abuse or mental illness) (Black, 2017). 47
Integration begins with minimal collaboration when healthcare providers and behavioral health providers are located in separate facilities but communicate on a case- by-case basis. Integrated care continues to grow with closer proximities, greater understanding of professional cultures and values, and with increased communication
(Heath, Wise Romero, & Reynolds, 2013). A fully integrated system may appear to have blended professional cultures and patient’s may perceive the services as a single health system to serve their complete needs. The Substance Abuse and Mental Health Services
Administration of the United States describes each level in their 2013 proposal (Heath et al., 2013). To increase integrated practice efforts in the future, inter-professional education and collaboration should be encouraged. Inter-professional education includes increasing student’s awareness of other professionals’ scope of practice, collaboration abilities, and critical thinking skills (Johnson & Freeman, 2014).
For dancers, there is no research that investigates the effects of accessing health clinics that are integrated in nature. However, there is literature which advocates for dancers to be able to access primary care physicians (Alimena et al., 2016) for screening and evaluation (Fulton, Burgi, Canizares, Sheets, & Butler, 2014) when they are dancing in pain (Anderson & Hanrahan, 2008) and managing psychological stressors (Noh,
Morris, & Anderson, 2003).
Complementary and alternative medical practices. The United State’s
National Center for Complementary and Integrated Health and the Australia government’s National Health and Medical Research Council share the same definition of alternative and complementary medicine. The Australian’s Resource for Clinicians to
Talking with Patients about these concepts acknowledged that since new complementary 48 products and therapies are ever developing, that defining practices into a category is difficult (National Health and Medical Research Council, 2014). However, for the sake of organization, “if a non-mainstream practice is used together with conventional medicine, it’s considered Complementary” whereas “if a non-mainstream practice is used in place of conventional medicine, it’s considered Alternative” (National Center for
Complementary and Integrative Health, 2011).
For non-conventional methods of injury prevention and self-care, dancers may turn to Somatic practices as well as complementary and alternative medicine. Through self-report, Thomas and Tarr found that 94% of dancers used some type of somatic or body technique and that there was a positive relationship between Alexander Technique and Feldenkrais and age, with older dancers taking part more than younger dancers. The opposite was found of yoga, with younger dancers being more likely to participate in yoga. The authors proposed that these techniques are increasing in popularity dance training. Complementary and alternative medicine (CAM) are defined as practices that are used with conventional practices (complementary) and practices are used in place of conventional practices (alternative) (National Center for Complementary and Integrative
Health, 2011). Although no literature was found describing dancers’ use of CAM, an article was published about Norwegian musicians. In a large-scale Norwegian study, researchers asked musicians about their alterative and complementary healthcare seeking behaviors; complementary medicines included: homeopath, acupuncturist, reflexologist, aroma therapist, healer, massage therapy, chiropractor, naprapath, and osteopath. The authors’ hypothesized that because musicians typically express an openness to experience, they would be more likely to engage in CAM. The resulting data and odds 49 ratio analysis showed that musicians were 2 to 3 times more likely to use a CAM practice than the general working population. Perhaps the same assumptions could be made of dancers.
When applying these concepts within dance medicine and science, several mind body practices are often taught such as Pilates, the Alexander technique, and Feldenkrais
Method as a part of undergraduate dance curriculum. Mind body practices such as Pilates have deep historical roots in dance and gymnastics. However, in a literature review of the
Journal Dance Medicine and Science, no relevant articles came from a search of the terms “alternative medicine”, “complementary medicine”, “acupuncture”, “massage”,
“yoga”, “Pilates”, “Alexander technique”, or “Feldenkrais method”. One article did discuss applying somatic approaches to dance education, which can benefit the dancer’s understanding of their own motor learning and anatomy. Overall, there was a dearth of literature that specifically addressed dancers’ use of alternative and complementary medicine practice consumption.
Conclusion
The purpose of this narrative study was to describe American and Australian dancers’ experiences of healthcare throughout their career, while considering the previous research done on these topics with an additional focus on times of pregnancy.
Examining country differences and similarities points to opportunities to improve and learn from international efforts to achieve a more integrated and efficient system that dancers can rely on for medical and mental healthcare. The following section explores the construction of the interview tools based upon the literature that has been presented.
50
The Interview Questions
The following section describes the interview guide which was created for the purposes of the current study; questions were generated from concepts and findings in relevant literature. Seeking knowledge about experiences through stories allows the researcher to understand the participant in context, via their stories, that might otherwise be lost (Clandinin & Connelly, 2000). The purpose of narrative inquiry is to “conceive, capture, and convey” these stories and furthermore, explore the meaning of both the stories and the experiences (Savin-Baden & Major, 2013, p. 231). Narrative inquiry was chosen specifically for this project to investigate questions that span the dancers career in order to understand how their access and satisfaction with healthcare have changed over this time. The interview begins with a “development as a dancer” tour question, this provides a broad description that allows the following questions to be more contextualized and pertinent to each interviewee (Rubin & Rubin, 2012, p. 137). Often during the tour question, future questions are answered or touched-upon. A model narration of a dancer’s career span comes from the article “Aspiring ballerinas and implications for counseling practice” by Tricia Sandham and Jennifer Kicol (Sandham &
Kicol, 2015). In their article, Sandham and Kicol briefly illustrate each dancer-participant in a short paragraph description of the dancers’ over-arching career, focused around end- of-career transitions. The remaining “Warm-up Questions are probes and an experience question. The two probe questions (Q0.2 What does the word healthcare mean to you? &
Q0.3 How often do you think about health insurance?) are meaning questions that allowed the interviewer to get an idea of how often the dancer comes across this topic and how they individually define the main concepts. The final warm-up question is an 51 experience question; as suggested in Rubin and Rubin (2012), an experience question allows for a broad introduction to a topic and allows the interviewee to choose an experience to illustrate a broad idea.
Part one. The vocation of dance is marked by tenuous job stability that can, in the
United States, make it difficult to sustain continuous medical care. It is the elite dance companies that typically offer longer contracts and medical support such as on-site clinicians or medial insurance (Requa & Garrick, 2005). At times of transition, such as pregnancy and injury, healthcare consumers rely on their health insurance scheme to support them more. Dance research supports the idea that high injury rates and the complications of being both pregnant and a dancer call for additional support from a mental health and medical care perspective (Jacobs, Hincapíe, & Cassidy, 2012; Sanders,
2008; Taylor, 2010). Therefore, part one of the questions aims to bring out the participants experiences in relation to injury and pregnancy (if the dancer has experienced these situations).
Injury. In the world of dance, some may feel that the ‘artistic capital’ of the dancer is enhanced through their pain, injury, and suffering and this “the permanence of pain in ballet is a measure of the validity of the charisma of a calling” (Wainwright, 2005, p. 57). On the contrary, injury can also “undermine the accomplishments that underpin the balletic habitus and the dancer’s identity” (Wainwright, 2005, p. 50). The fear of losing control over the body, remaining fit, and retaining skill level can press dancers to disregard medical practitioners’ suggestions to take a rest to promote healing (Lai et al.,
2008, p. 51). Furthermore, taking time off from dance can often be interpreted as “daily losses of opportunities to further one’s career” (Wainwright, 2005, p. 54). It is for these 52 reasons that the management of injury is asked about in part two of the interview guide.
These questions began with a focused main question which naturally lends itself to follow-up questions such as a how question and a financial component question (Rubin &
Rubin, 2012).
Pregnancy. As many iconic female dancers remained childless, there may be an artistic stigma attached to choosing motherhood over dance, evidenced in the participant- quote: “a true dancer lives for her art and nothing else” (Aalten, 2005, p. 5; Taylor,
2010). However, “both a dancer’s performing life and a woman’s fertile life are short”; this is a provoking statement from a 2010 Dancing Times article which explored the dualism of being both a dancer and pregnant (Taylor, 2010, p. 23). There is little scientific evidence available for expecting dancers to rely on in terms of health guidelines for dancing pregnant.
Most guidelines for pregnant dancers are extrapolated from sport and exercise sciences and in 2008, Sanders, a registered nurse, discussed the musculoskeletal changes that come with pregnancy. Some of these changes are abdominal muscles losing the ability to stabilize the pelvis, increased back pain, the pubis symphysis needing special attention, and the wrists may retain fluid more than pre-pregnancy which is uniquely problematic for Flamenco dancers (Sanders, 2008). Some physiological conditions that a dancer should be aware of such as keeping a cooler internal temperature, maintaining adequate blood flow to the fetus, increased caloric needs, and considering levels of intensity differently than in her pre-pregnant status (Sanders, 2008). With so many considerations, adequate access to healthcare and a working relationship with an 53 obstetrician is desirable, however, Sanders does not mention dancer’s access to such services, or at what cost.
Again, professional tensions exist for most working women who are pregnant or considering pregnancy, however, this decision can be uniquely poignant for a female dancer whose achievements are measured by her body (Taylor, 2010, p. 23). When a dancer begins contemplating the possibility of bearing children, this can mean “the starting point for a re-thinking of their career and their ambitions” (Aalten, 2005, p. 12).
In a 2005 qualitative study of dancers in Holland, the author wrote “most female ballet dancers are not willing to give up motherhood for dancing” (Aalten, 2005, p. 12). Besides several dancer-related magazines and borrowing from sport science, there is little specialty knowledge published for expecting dancers. As an exploratory, open-ended question, this researcher asked pre-identified dancer mothers: “How did pregnancy, dancing, and healthcare intersect?”
Part two. The third section of questions aims to paint a picture of dancers access to healthcare services; each question was written to explore the different components of access. Given her research in Holland, Air concluded that healthcare access improved with universal healthcare systems in comparison to a marketplace system. However, this work was done in 2008, before the Patient Protection and Affordable Care Act were signed into law. Furthermore, factors such as network of providers, company support, and public healthcare programs can influence access as identified from the reports in Cuba and Australia (Babin, 2007; Hadok, 2008). The final question is almost a precursor to the following section – in asking about the level of support a dancer feels, the interviewer is 54 trying to assess if the dancer has had a more positive or negative experience in accessing healthcare that they find satisfactory.
Part three. The final ‘part’ of the interview guide focuses more on the dancers satisfaction through seven questions. Q3.1 is close to a hypothetical question in asking the dancer to verbally illustrate what they would want from healthcare – either in a structural or interpersonal way. This question may lead the interviewee to talk about extreme cases where they were very satisfied or very unsatisfied with care they received.
The literature often points to communication as a barrier to dancers’ satisfaction with medical care; this may be reflected in this question (Air, 2009; Lai et al., 2008). The second question and its follow-up questions were mini-tour questions which open up a chance to discuss dance specific services and the potential for stories that can compare experiences (Rubin & Rubin, 2012).
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Chapter Three: Methodology
Research Design
The purpose of this study was to focus on dancers’ perceptions of, satisfaction with, and access to past healthcare experiences in two countries that have different healthcare models: the United States and Australia. This research used a qualitative approach to understand the experiences of American dancers and the experiences of
Australian dancers to discover the unique and similar qualities between the two groups’.
A qualitative design was chosen as a means to understand the practical issues that this population experience as well as to create a work of advocacy, giving dancers’ voice a place in the body of research which typically discusses their access and satisfaction to medical and psychological services without them.
Narrative inquiry. The approach of narrative inquiry was selected to focus on how dancers experience their world and how they make meaning from their healthcare experiences; also known as a social constructionism approach (Rubin & Rubin, 2012).
Clandinin and Connelly (2000) wrote that because people develop their views and learn through the stories they hear and tell themselves, it is a logical step to research people through collecting their stories (p. 17). Moreover, gathering personal stories from this patient population aimed at discovering the practical problems that may hinder dancers achieving the best healthcare. Furthermore, “life is experienced on a continuum” and experiences are connected to past experiences; narrative inquiry was appropriate to look back in time and collect stories from memories (Clandinin & Connelly, 2000, p. 19). This method was chosen so that a retrospective look at the dancers’ career could be captured, going back to their development as a dancer to their current professional status. 56
Using narrative inquiry to guide to preparation, data collection, and analysis, I assembled the narratives of dancers of varying levels (always self-identified as professional), genres, and in two countries from July 2017 through August 2018. The aim was accomplished by in-depth interviews and a screening survey tool created from the previous research of Dr. Air’s study done with Dutch dancers (Air, 2009; Chimenti et al.,
2013; Jeffri et al., 2011). This combination of data sources provided a secondary vantage point of dancers’ experiences with access and satisfaction with healthcare. Triangulation of the data was done to support the credibility and trustworthiness of the research.
Partial life stories were collected from each participant; partial because the scope of the research is specified and not open. The focus of the interview and narrative approach was to understand the career trajectory, which in turn influenced proceeding questions about healthcare and health insurance. Furthermore, dancers who experienced pregnancy were asked to describe of their experiences being pregnant while dancing. The combined elements of this study are personal accounts and narratives, a dancer’s story, framed within an advocacy lens.
Researcher’s lens. Coming to dance late, it wasn’t until I was a college-aged student that I began dance technique classes such as Jazz, Ballet, and Modern dance.
Simultaneously, as an American undergraduate student, I was in an athletic program, learning about sports medicine and taking care of injured athletes in clinical work. It was during this time that I began my independent study of dance medicine; through conferences, independent coursework, and research that I pieced together my knowledge of the field of dance medicine and science. Furthermore, I wanted an immersive experience; I applied and was accepted into a Dance Science master’s education program 57 at the Laban Institute in London, England. In addition to meeting many dancers and hearing their stories of injury and performance, I was exposed to England’s universal healthcare system. After this year abroad, I practiced as an athletic trainer in several sports and performing arts settings until I began my doctoral studies. My doctoral program is in athletic training and professional counseling – both of which are professional programs geared to decreasing burden and enhancing performance. I aimed to relate to the participants through both my experiences at dance schools, as a dance researcher, and as an advocate for their health.
These previous experiences had given me opportunities to speak with dancers and to practice interviewing skills. As an athletic trainer, I practiced clinical interviewing with a performing arts population for three years. As a student of professional counseling, I practiced therapeutic counseling in an educational setting. As a part of my scholarly coursework, I conducted four interviews, of varying lengths, formats, and purposes.
Through my studies of qualitative design over the past year, I’ve encountered several texts that I relied on during my data collection and reporting such as Creswell (2002),
Rubin and Rubin (2012), and Clandinin and Connelly (2000).
Data Collection
The data collection period for this research lasted between September 2016 through May 2017 in the United States (New York and greater-Boston) and between June
2017 and August 2017 in Australia (Sydney, Melbourne, and Brisbane).
Participants. The participants for this study were all adult professional dancers.
Having excluded exotic and recreational dancers, all other professional dancers who spoke and understand the English language could be included. Professional dancer status 58 was self-declared using two questions (found in Appendix B: Pre-interview Survey).
Primary form of dance was unspecified. Percentage of yearly wages were not used to differentiate between professional and amateur dancers as done by Jeffri et al (2011) in their depiction of aging visual artists in New York City.
For the purpose of recruitment, participants should also have been responsible for their own healthcare meaning that the financial responsibility of covering healthcare belongs to the dancer and not a spouse or parent, as well as including being covered as a part of an employment remuneration package. In the United States, adults over the age of
26 were be targeted due to the Young Adult Coverage provision under the Affordable
Care Act that allows individuals to remain on their parents’ insurance until age 26; this carries with it the assumption that individuals over 26 are somewhat more informed about their own health insurance. In Australia, children may stay on their parent’s private health insurance until they are 25 and all Australian citizens have access to the public healthcare system; responsibility was interpreted as individual dance artists who purchase their own private health insurance or are provided health insurance by means of an employment remuneration package. This criteria was adhered to with the exceptions of the cases of
Gwen (Australia) and Fern (United States) due to a lack of age screening before the interview session and the unique positive addition their insight gave to the research.
Selection of participants. Seeking out American and Australian dancers that represented a varied definition of professional status was essential to this research.
Dancers that were working within a company and outside of a company were targeted equally; non-companied dancers are an underrepresented group in the dance health literature, although there are a number of expectations to that rule. 59
Opportunistic sampling and a chain-referral recruitment process were used to achieve maximal variation sampling; this was to develop as many perspectives within the pool of participants (Creswell, 2002, p. 207). The chain referral technique was used in a
2010 research study to contact aging New York city painters, the argument being that artistic communities are often connected through personal networks rather than professional organizations (Jeffri et al., 2011). However, these researchers had difficulty finding a racially representative sample of New York City. To counteract this, a conscious effort was made to contact companies such as Alvin Ailey, Brown Girls do
Ballet, and Dance AA.
Opportunistic sampling was also applied to take advantage of locally available dancers, dance companies, and dance organizations. Advertising for the research was placed through groups such as Boston Dance Alliance and AusDance on their social media accounts and email communication newsletters. Personal connections to dancers were employed to strategically find varied experiences through chain-sampling.
Specifically in Australia, the Dance Research Collaborative (DaRC) provided a list, which was fully utilized, of Australian dancers who had participated in past research and indicated they were open to being contacted for further research. Through these avenues, twenty dancers were successfully recruited. No compensation was offered to aid in recruitment efforts. A variety of recruitment strategies were employed concurrently to attract participants for interviews until the proposed recruitment target of 20 dancers was reached. Participation was voluntary; dancers who responded to the various recruitment methods may differ from those who did not respond. 60
Procedure. The Ohio University Institutional Review Board accepted the ethics proposal in June of 2016. The University of Sydney Instructional Review Board accepted the ethics proposal in June of 2017. Both documents can be found in Appendix A.
Participants were contacted through the various means as outlined above and all communication was achieved through email. Once a participant expressed interest in the study, a copy of the pre-interview survey and copy of the informed consent form was sent back to them via the website Qualtrics. For Australian participants, a separate paper version of the informed consent form was signed in pen and collected at the time of the interview. After the completion of the pre-interview survey, I confirmed that the participant identified as a professional dancer and then began communication to set up a
2-hour time block and location for the interview. Moreover, at this time I recorded the chosen pseudonym from the pre-interview survey.
Locations differed greatly depending of dancer location; refer to Table 2 to read more about locations and settings of the interviews. A common choice in the United
States was through a company called Breather that offers short-term (as little at 30 minute) office space rentals. In Sydney, the University of Sydney was quite central and was the first proposed location. Three dancers agreed to have their interviews take place over Skype or Google Hangouts, the reasoning for which was a snowstorm (New York) and distance (Darwin and Townsville). Australian dancers interviewed using Skype were asked to re-read and digitally sign the informed consent form within 30 minutes prior to the interview.
At the time of the interviews, I allowed for several moments of introductions and rapport building. I encouraged the dancers to let me start recording once they began 61 speaking about themselves in the role of a dancer. Recordings were taken with both my iPhone and a LiveScribe pen; the iPhone offered superior quality for transcription. Field notes were recorded exclusively on a LiveScribe notebook with the recording LiveScribe pen. The field notes were identified by the chosen and confirmed pseudonym for the dancer.
In cases where participants revealed tensions such as interpersonal problems within their community, fictionalized interim research texts were used to protect the teller’s identity (Creswell, 2002, p. 513). This is an ethical tool that omits a detail while leaving intact the representative concepts in the narrative, but not an individual’s story; I practiced increasing my sensitivity and empathy to these situations to protect my participants. A second method of ethical protection was the use of pseudonyms for all participants. A further consideration in ethical narrative research was maintaining the participant’s voice; this was managed by being mindful of and respecting power differentials as well as keeping stories as contextualized as possible (Creswell, 2002, p.
513)
The timeline for the research was between June 2016 through May 2018.
American data collection took place between June 2016 and May 2017. Australian data collection took place between June 2017 through August 2017. Transcription and data analysis began in March of 2017 and continued through April 2018. In the United States,
New England states and New York were targeted for recruitment for practical traveling concerns via automobile. In Australia, seven interviews took place in Sydney and were reached via the public train system while three interviews took place in either Melbourne or Brisbane, for which plane tickets were purchased. These places were chosen for the 62 availability of dance science researchers, ease of travel as they are all on the east coast, and have a known dance population.
Data analysis began and was ongoing once four interviews had been completed.
Beginning with transcription via a professional transcription service, data analysis included listening to recordings, reading transcripts, and completing an initial coding. No further analysis was completed during the simultaneous data collection phase.
The pre-interview survey. Two survey instruments were developed by Dr.
Mamie Air “to collect epidemiologic data about dance-related injury and the dancer’s access to healthcare “Healthcare Access Survey” [HCA], as well as levels of pain, confidence, and satisfaction with medical treatment “Perceptions Survey” (Air, 2009, p.
43). These tools were “reviewed by a panel of dance medicine experts at the Medical
Center for Dancers and Musicians and approved by the Medical Ethics Committee of
Southwest Holland” (Air, 2009, p. 21). After being inspired by and having a conversation with Dr. Air at the 2015 IADMS Annual Meeting, these pre-existing tools were selected and adapted specifically because they were created for a dancer population and aim to collect data about access and satisfaction from past healthcare experiences.
Using the pre-existing English version, this research adapted these instruments to retain the same focus yet was more reliable for the context of the current study. The resulting survey was known as the “pre-interview survey”, found in Appendix B. A major difference between the 2009 study and the current study is the sampling of dancers; Dr.
Air surveyed from a dance medicine clinic from currently injured dancers. This research adapted her instruments to reflect a past injury, but assumes no present contact with a medical office. Furthermore, the survey was given at the time preceding the interview, 63 whereas in the 2009 study, the Perceptions Survey was administered pre and post a physician visit. The construct of pain was removed, as sampling did not include seeking currently injured dancers. The purpose of the survey was to aid in triangulation of the data as well as collect certain information such as how the participants define their professional dancer status and monetary information.
The interview. The primary form of data collection was responsive, in-depth qualitative interviews which allowed me to create rich and detailed information with the interviewee. Questions were mostly open-ended in a semi-structured design and the interviews lasted approximately one hour to 90 minutes, with only the first interview lasting two-hours and thirty-minutes. Detail, depth, vividness, nuance and richness were each considered when formulating questions and in conceptualizing the kind of answered returned (Rubin & Rubin, 2012). The details of the interview guide development, including conceptual framework and guiding literature, are found in chapter two. A copy of the finalized interview guide can be found in Appendix C.
Using responsive interviewing, a friendly and supportive tone was prioritized and emerging data/themes were welcomed in the process. Furthermore, this approach allowed the most prevalent questions to be asked while the semi-structured design kept the purpose focused. Due to the research subject, the information needed required topical interviews and called for the collection of facts, descriptions, and examples that work towards answering the main research questions. Topical studies ask the what’s, when’s, how’s and whys of their participants (Rubin & Rubin, 2012, pp. 31–32). The interviews were conducted in a private room with each participant in an acquirable and practical local location agreed upon between the participant and myself. 64
Validation strategy. Several techniques were used to increase this work’s trustworthiness. The use of multiple sources were achieved by collecting data from different places, vantages points, and time. In the current study, the purposeful sampling consists of dancers who have experienced different conditions (vantage point), different countries and cities (place), and at different points in various dancer’s careers (time).
Second, I practiced reflexivity throughout this process by keeping a reflections journal as well as an analytic journal. Reflexivity is a “continual self-awareness and critical self-reflection by the researcher on his or her potential biases and predispositions as these may affect the research process and conclusions” (Johnson & Christensen, 2014, p. 301). As a student of counseling, I’ve taken classes such as multicultural education, human development over the lifespan, and theories and techniques; each of these courses addresses self-awareness as foundation to working with people, of the same or different culture. I feel throughout the past three years of developing and conducting the study that
I have actively worked to become more aware of myself in society and increase my awareness and knowledge of other viewpoints.
In addition to using multiple sources, being careful with voice, and practicing reflexivity, the interview guide was tested in three samples to further increase validity.
The first sample was a part of a class project; the subjects were three dance professors and IRB approval was granted. The second piloting was done through personal contacts with two dancers (one American and one Dutch) and one Australian non-dancer resident; they were instructed to read through the questions and clarify meanings and interpretations when necessary. Finally, as a part of a separate class, the tool was discussed in a group setting with fellow qualitative researchers to assess again for clarity 65 and sequencing. Based on the feedback of the individuals, feedback from the class cohort, and responses of the dance professors – adjustments to the interview guide were made to be more clear and poignant.
Data Analysis
Procedure. Simultaneous transcription and data collection were ongoing from
March 2017 through October 2017; two examples of the resulting transcripts can be found in Appendix E. From the first interview in June 2016, analytic memos were taken as well as writing in the reflective journal. The process of preliminary Holistic Coding began once the first transcript was completed in April 2017 and was completed in
October 2017. Holistic coding is “appropriate for beginner coders” and was well suited for the episodic excerpts that I collected through the semi-structured interviews (Saldaña,
2013, p. 142); it is a style of coding that “attempts to grasp basic themes or issues in the data by absorbing them as a whole” (Saldaña, 2013, p. 118). From October 2017 through
December 2017; after having read whole and portions of transcripts several times and identifying codes, pattern coding by hand was used to begin to identify emergent themes and pull information together (Saldaña, 2013, p. 210). Pattern coding is a way of
“grouping summaries into a smaller number of sets, themes, and constructs” (Saldaña,
2013, p. 152). Discriminate cases were considered, but ultimately no interviews were determined to be such an outlier as to be excluded from the research.
Reporting results began with a case-by-case description of each participant that considered the interview and demographic information of each participant and named them according to their pseudonym. The process of retelling of the participants’ story included member checking and participant-feedback to validate the accuracy of the re- 66 telling. Every participant was sent back their re-storied interview and given two weeks to respond with feedback or clarifications; 16 participants took advantage of this process and submitted varying levels of feedback which was then incorporated.
The second reporting of results considered the four initial research questions and presented information rich with direct participant stories and quotations. The organized and interpreted data was evaluated on the depth, accuracy, persuasiveness, and realism of the accounts given (Creswell, 2002). Each code was printed and re-coded by hand to find emergent sub-themes; the final code book can be seen in Appendix F. These were referenced back to the re-stories and transcripts for accuracy and reported if they were evaluated to be accurate and reflect the reality the dancers presented. A visual representation of this process can be seen at the end of this chapter.
Computer program. Transcription was completed through a professional transcription service. All transcripts, digitized consent forms, and recordings were stored on both university’s preferred storage system (Box and Research Data Store) as well as on Dropbox and my local hard drive for ease of access while in active analysis. For coding software, the Computer Assisted Qualitative Data Analysis (CAQDAS) system
MAXQDA was used to categorize, code, and retrieve data during analysis. This program helped keep me aware of the frequency of codes appearing across interviews and field notes as well as provided insight into potential emergent themes (Saldaña, 2013, p. 22).
Validation Strategy. To be an active reflexive researcher, I dedicated a recurring part of the analysis process to identifying biases, predispositions, and re-evaluate my found interpreted meanings. This process included checking my interpretations with 67 peers and advisors, initially coding as I received transcribed interview data, and maintaining a reflective journal on the research project including analytic memos.
To increase the interpretive validity, I asked each participant about their willingness to receive my re-storied version of their interviews for their feedback. This follow-up served as a chance to touch base and in some cases without prompting, receive follow-up information to their health status. Sixteen of the 20 dancers did provide some feedback to their re-story. Specifically in Australia, I collaborated with fellow Australian dance researchers at the Dance Research Lab at the University of Sydney such as my advisor Dr. Claire Hiller, her associate Dr. Evangelos Pappas, and a fellow PhD student, dance-researcher Amy Vassallo. This collaboration served to check my understanding of
Australian culture and knowledge of the contextual information I was gathering from interviews.
Finally, I employed preliminary coding while the Australian data collection was occurring. This process allowed me to work more closely with my data and gain insight that directly influenced my interview questioning. Finally, my researcher’s reflective journal was a place where I asked questions such as: What did I learn from this? Why does this matter? And, what surprised me? In conclusion, the data analysis portion of my validity plan included independent self-review as well as the work of others to check my re-stories and interpretations.
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Visualization of Analysis
Figure 1: Visualization of Analysis
69
Chapter Four: Interview Summaries
Introduction
This chapter contains the summaries of the 20 participant interviews; 10
Australian participants and 10 American participants; for a brief version of this chapter please see Appendix D. The interviews took place over the course of one year (August
2016 - August 2017). They began in a small-town library in Massachusetts and ended in a large state library in New South Wales. Collecting these interviews happened on weekends during the American school year and over the course of a summer / Australian winter in 2017 while I was living in Sydney for this project. I was able to see multiple dance performances over the course of this year, including some of my participants’ works. Each individual brings to this research a lifetime of interacting with healthcare, speaking about self-care, physical training, learning about themselves, and much more that I attempted to tap into over the course of an hour to two hours. Each story is member checked by the dancer to ensure a collaborative truth to their story.
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Table 1: Participants per Interview Date
Dancer Interview Location Setting Dance Status Date
Vivian 9/5/16 New York City Community room Freelance
Nora 12/23/16 Boston Residence Retired teacher
Fern 2/25/17 New York City Breather room Freelance
Sam 3/12/17 Connecticut Residence Companied
Jade 3/24/17 New York City Breather room Freelance
Zoe 3/30/17 New Hampshire Community room Company director
Benjamin 4-7-17 Boston Classroom Freelance
Coral 4-11-17 New York Dance Studio Teacher / dancer
Olivia 4/30/17 New York City Breather room Freelance
Quinn 5/12/2017 Skype New York City Teacher
Piper 6/30/17 Sydney Library room Freelance
Alynn 7/12/27 Skype Townsville home Companied
Harper 7/29/17 Sydney Residence Teacher / dancer
Una 8/3/17 Sydney Library room Retired
Gwen 8/7/17 Brisbane Library room Teacher
Liam 8/7/17 Brisbane Library room Companied
Emerson 8/12/17 Melbourne Public library Companied
Yasmin 8/10/17 Sydney Library room Teacher
Kat 8/14/17 Sydney Library room Pilates / teacher
Ida 8/17/17 Skype Darwin home Companied
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Vivian
New York, September 2016. My interview with Vivian was the second of this project. She responded to an advertisement that I posted to a Boston-based dance organization’s newsletter earlier that summer. We met on Labor day in a meeting room within a LGBTQ+ community center in Manhattan, nearby a rehearsal she would have later that evening. Her career has largely been based in Boston before moving to New
York City 15 years prior.
Vivian graduated with a Bachelor’s of Art in Creative Arts with a concentration in
Theater and Dance from a small college in Massachusetts which has since closed its doors. After graduation, Vivian began a 17-year full-time career dancing in and around
Boston. After this time she was offered a part-time teaching position at a college in New
York City teaching dance one semester per year. For the past decade, she has split her year between living partially in Boston and New York City as a dancer and dance professor.
Right away when Vivian began speaking about her body and some of the injuries she’s endured, there is a pattern of chronicity and long-term effects. Beginning with her insurance plan, during her time in Boston, Vivian enjoyed an employer-supported insurance policy. Since transitioning to part-time positions, her numerous employers do not offer their own insurance policies to buy into. She did purchase a COBRA plan for 6 months but the cost was not sustainable. This transition left Vivian without insurance for about six years in the mid-2000s. Five years ago, in consulting with a social worker for an unrelated topic, Vivian found she qualified for the Mass Health public insurance system due to her income; with her teaching position and subletting her apartment to 72 subsidize her rent, she notes she’s “making it work”. The process of obtaining insurance coverage through MassHealth was not without trial as Vivian recounted it took a full year and three attempts to file the appropriate paperwork.
Although she expressed the importance of having insurance, Vivian was clear about her thoughts about interacting with insurance companies’ customer service agents saying that she “doesn’t trust insurance people at all”. Providing an example to support her feelings she noted that during the course of physical therapy for an Achilles tendinitis she was managing, there was a “snafu” in communication with an insurance agent. The insurance company told her she had reached the maximum appointments with a physical therapist - when in fact that was not true. Subsequently, her appointments were halted for several weeks while she had to sort out the error with numerous customer service calls to the insurance company. She said from this she’s learned to let her practitioners deal with calling the insurance company rather than calling herself.
During her time lacking insurance, she remarked to me that she made it six years without running into an issue. However, at the six year mark approximately, she began experiencing tooth pain. This is where a long “chain of events” started off. From not having insurance she was not able to afford preventative dental medicine. The tooth pain was a tooth infection which in turn needed a root canal. Unable to afford a root canal out- of-pocket, Vivian did a few things. She first sought care from a dental school, noting that seeing dentists-in-training is about half the cost and she was reassured by the student’s being supervised. Next, at one point, she opted for an extraction rather than a root canal, this was a less expensive option for her. She repeated this process several times over the course of 2.5 years because she kept having dental issues and tooth pain. She lamented “I 73 now realize that I should have, found a way to just [buy preventative dental care earlier], because it cost me a lot more in the long run with root canals and I am missing a tooth now”.
Moreover, during this period of tooth infections and dental work, Vivian was prescribed antibiotic medication multiple times. She then experienced a slew of ear infections, bronchitis, and pneumonia for months remarking that she only remembered a
3 week period of total wellness in the course of three years. After gaining control of her dental situation, obtaining MassHealth, and recovering from her long illnesses, Vivian began dancing again about 2 years prior to our interview. In that time she has experienced plantar fasciitis, Achilles tendinitis, a torn hamstring, undiagnosed knee pain, and a rotator cuff; each pathology on the right side of her body and each injury she attributed to the long-term illness she had, in her words:
the physical therapy that I had to do this year is a direct result of the year of
having pneumonia [in which] I wasn't dancing, everything got weak, and when I
started dancing again, I had one injury after another. So it’s been this chain of
effect that has brought me to today.
She is managing some of her current injuries with massage and others with physical therapy. She remarked that her strength was still not completely recovered from her period of illness, but she was still dancing and working towards a stronger point.
Vivian shared with me one additional injury that was a chronic issue in her dancing life. She didn’t name the exact injury, seemingly unsure of what final diagnosis was reached - but it involved a nerve entrapment near the second metatarsal of her foot.
The pain developed when she was in Boston dancing full-time, so the treatments and 74 evaluations were covered by insurance. Throughout seeking care for her foot pain, Vivian remarked that she had been to each of the major hospitals in Boston looking for relief.
Her foot was imaged several times and she was prescribed multiple cortisone injections, metatarsal pads, and orthotics which were an out-of-pocket cost of $250. While not perfect, she reflected that the metatarsal pads were the best treatment option she had for a while. Moreover, Vivian said “I lost my job with the company I was in because I couldn't dance; their season started and I wasn't able, I couldn't even walk to rehearsal”.
Additionally, she visited several holistic practitioners and said “I went to a naturopathic doctor; he gave me some anti-inflammatory treatments acupuncture, magnets, herbal turmeric anti-inflammatory things that worked better and I went to a homeopathic practitioner and there was a dramatic improvement with that, and then it just leveled out to a place where I could get around, I could walk, but I couldn't dance very well”.
All in all, Vivian highlighted that about 20 years passed by before she felt her pain was completely resolved which happened during a period of time of intense training
(8+ hours of dancing each day) where she was able to significantly build up the strength in her feet and purchased wider shoes to dance in. Her final words on that matter were: “I won't say it ended my dance career completely because I was still teaching, but it ended my performing”.
When asked about preventative care in the current day, Vivian expressed great satisfaction with her current primary care physician in Boston. She calls this physician
“out of the box” from, being a transgendered person and offering services such as acupuncture from her office. She notes that she feels that she can talk to her and is listened to, a feeling she expressed was lacking with other practitioners. With her current 75 primary care physician, Vivian notes “she’s really been doing a lot of blood work finding out that I'm like pre-diabetes all these other things whereas the other doctors just wanted me to go get mammogram”.
Vivian feels that coming into her 30s she became a more knowledgeable patient, looking up information before her appointments so that she could be more informed before hearing the physician’s diagnosis and prognosis. During her foot pain and the management of previous dance injuries, Vivian recounted that she had gone through rehabilitation plans that she was at odds with. However, now she feels that she is able to advocate for what she wants and moreover, feels the communication between her and her current physician facilitates this ability: “if I didn't have the doctor I have I wouldn't I would go back and insist”.
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Nora
New England, December 2016. I met Nora in a shopping mall while we were waiting for service in a tech store together. I inquired about her tap shoe necklace, and our ensuing conversation led to an interview for this project. For Nora, dance was her second career. Her first career was in social work, working in a Boston-area hospital where as a young woman she met her husband, a medical resident. When we met, Nora had been retired from teaching tap dance professionally for about a year. For these reasons, Nora is a unique outlier to the other dancers in this research.
Nora was born in New York City to a father who managed national tours of
Broadway shows. As a child, Nora wanted to be a professional dancer; however, she was thwarted by her father who deemed her “too short and too fat” for most forms of dance with the exception of tap. She recalled that she loved her tap lessons and tap shoes; she ended up in tap dance classes from the ages five to nine. When she stopped dancing at age nine it was, largely due to her family moving around and Nora becoming more serious about her school studies. She starting dancing again at the age of 41. Between these two points in time, she earned a Bachelor’s and Master’s degree, practiced as a medical social worker at a Boston hospital, and became a mom to two daughters.
At the age of 41, Nora describes developing a “burning desire” to begin tap dancing again. She took classes and trained privately with two teachers in the Boston area, one who founded the tap dance program at the conservatory where Nora taught.
About four years into her private tap dance training, this teacher gave Nora two of her own classes to teach. She told me that without a degree in music or dance, having studied only piano in her youth, she “worked to be a teacher on the job”. Nora performed with 77 her teachers on several occasions, and enjoyed teaching tap for musical theater majors for twenty years before she voluntarily retired. Two weeks later, her older daughter became ill with surgical issues she had had since birth.
In Nora’s words, “healthcare is everything...even if you are healthy and you don't think you need it, because when you need it - oh my God”. She related this importance to her birth of her two daughters; the eldest was born with hydrocephalus due to a pregnancy affected by toxoplasmosis and is legally blind, and the younger daughter was born with pulmonary atresia. Both daughters are currently in their 30s. Through being a mother, Nora has managed many interactions with multiple medical professionals at several hospitals.
First and foremost, Nora has experience with the trials and tribulations of seeing the right physician. Reflecting on one incident, Nora reflected on a time when her husband was able to get their daughter an appointment with a specialist quickly when needed:
If you go to an ER and you do not know how to negotiate the system, you may
not to get to see the right practitioner, and it can be a nightmare. My husband
called and we got an appointment to be seen urgently in the practice where she
was already receiving care. She had the worst acute episode of glaucoma the
ophthalmologist had ever seen. We were there for five hours, while they broke the
episode with drops[.] We needed them right then and there and we were one of
the lucky ones, I was able to get an appointment right there and then, but I
wouldn't have been able to do that if my husband wasn't a doctor. 78
From Nora’s stories I sensed how fortunate she felt for her and her family that her husband (as a physician) was able to coordinate much of their daughters medical care - seeing the “best of the of best” as Nora relayed to me. The advantage was not only for their daughters but also for Nora as she stated that she “had a GI bleed in 1995, a rather big one, and so [her husband] got the best GI person to come see [her] right away in the
Emergency room, it’s that kind of thing.” Even before she was married, she told me of once when she was a medical social worker and developed recurrent, vertigo-inducing headaches. Because she worked in a hospital, she was able to casually ask a doctor for help and her case ended up being managed by a then-famous neurologist. Nora expressed that “access is a mystery”, and “had I not been working at a hospital, I wouldn't have known what to do. I don't think people know what to do”. Furthermore, she noted that many of her friends and extended family have called her husband for help and she relates finding a quality practitioner to fishing “in a big sea”.
Nora has had one orthopedic surgery which she detailed to me. The initial injury happened in February during a semester when she taught ten dance classes each week. As she was closing up the studio to leave, she felt a popping sensation, later confirmed to be her quadriceps, as she bent over. She attributed this injury to not stretching enough after class, having had a negative interaction with a student, and a particularly cold space in the building. At this point in time she also had an on-and-off-again habit of wearing a knee brace for support, which she was not wearing in the moment of injury. She did not seek treatment directly after, but it was her husband that encouraged her to get an MRI after the pain remained for some time. The radiologist observed a substantial amount of damage had been done and expressed an urgency that she heal or else she would “ruin her 79 knee”. After several months of physical therapy with repetitive leg exercises she felt back to herself. Unfortunately, the following August (six months after her initial injury) she felt another ‘pop’ and ended up needing an meniscus repair just two weeks later.
When I inquired how affordable treatment and rehabilitation has been for her, she called the process “crazy”. Nora noted that each year since Obamacare was instituted, the premium for her daughters premium insurance rose. Similarly, her and her husband’s
Medicare premiums had been costing more than what they paid for their private health insurance before they had Medicare. She noted “we are being [additionally] taxed because we have a better [Medicare] plan than some people”. Before subscribing to
Medicare, Nora had consistently been a part of her husband’s insurance plan because since she had been a part-time dance teacher for over two decades; this rendered her ineligible to buy into her employer’s health insurance plans. However, despite having had a premium private insurance policy, Nora still had out-of-pocket payments. She paid for orthotics ($500) and partially for physical therapy sessions which lasting longer than the allotted amount; both costs were in relation to having spondylolisthesis. She exclaimed,
“[it’s] a shame that coverage is so minimal”.
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Fern
New York, February 2017. I sat with Fern in February in New York City. I rented a small meeting room with a lovely view of lower Manhattan rooftops and water towers.
We just happened to be around the corner from Fern’s moonlighting job at a clothing retailer as a funny coincidence. Fern is a freshly minted college graduate, my youngest interviewee, recovering from an injury, and has just moved back to living in New York
City, being originally from Long Island. She considers herself a contemporary dancer and has trained since she was three, starting with ballet, and progressing onto studying at a contemporary dance conservatory in Massachusetts for her Bachelor’s degree of Fine
Arts and previously at a performing arts high school in the same state. She plans to play what she calls the “professional dancer game” for a while and (not wanting to limit herself) is interested in dancing for gallery shows, solo site-specific pieces, and within a company should these opportunities arise.
Fern finds her dance career to be highly influenced from her injury history and the training opportunities she’s had. Her trajectory and relationship to movement is interlaced with Alexander technique which she was exposed to in college. She is very interested in improvisation as she feels it best compliments her natural abilities as a mover. Rooted in her injury history, Fern was introduced to improvisation in college and found it allowed her to “tap into different ways of moving” so she felt that she could work with her adjusted movement patterns (due to injuries) and not fight them to produce a specific technique. Learning how to access different movement through her injuries was helped greatly by an improvisation professor she had. By tapping into different ways of moving, 81
Fern found a style that complimented her facility rather than making her feel like her injuries were hindering her from a genre.
Fern finds healthcare to be a collaborative process and more specifically that dance medicine is still evolving. She currently does not have a primary care provider but is working towards building up a network of healthcare professionals via friend and peer references. Fern described her injuries as “complicated”, “chronic”, and “complex” as well as entwined with her mental health. She notes that since college, she has been managing diagnosed anxiety and depression and pointed out parallels between these conditions and the onset of longer lasting physical injuries. She observes in herself that a lack of clarity in her mind translates to a lack of clarity in movement.
By virtue of her age, Fern is currently on her parent’s health insurance plan. Her moonlighting job in New York City does offer health insurance to its employees, but
Fern plans to remain on her parent’s until she is no longer qualified in a few years. She has never experienced being uninsured, and her high school and college performing arts programs both offered a student health insurance plan had she needed it. She mentioned that she does not feel financially stable enough to attempt to access everything that her current health insurance policy doesn’t cover (more physical therapy visits or an extra doctor’s appointment). Due to the chronic nature of her injuries, she has experienced the limitations of her plan, specifically in the maximum number of physical therapy visits it entitles her.
Fern proceeded to describe her catalogue of injuries to me, detailing the events and how she has adapted her dance to accommodate the more chronic injuries. The first injury she relayed was a peroneal tendon injury, described as her most “cut and dry” 82 recovery process. Fern told me that it felt like a standard “dancer-gets-injured, goes to the emergency room” scenario. She had gone to Children’s hospital and was quickly diagnosed and given a boot and crutches to wear and use. She was then able to see a sports medicine specialist from the hospital affiliated with her conservatory for follow ups. Fern remembered that during the time that she was not dancing she was still a barista at a local coffee shop which in hindsight, she realizes that she shouldn’t have done.
Returning to dance was a slow process, but Fern felt prepared for each stage working with both the in-house physical therapist and going to a local physical therapy office. The hardest part for rehabilitation for her was and still is the return to dance when the dancer is forced to consciously control their participation levels without overextending and comparing themselves to where they were before they were injured.
The next injury that Fern detailed was less of a single injury and more of an amalgamation of muscular strains ranging from her adductors, hamstrings, and lower abdominals. These all happened when she was a freshman at a dance conservatory and before she had a greater awareness of her own anatomy and body. Over the span of three months while in training, Fern sought out a diagnosis for her pain and came up with multiple explanations and some medical professionals gave her no diagnosis at all. She felt that no one explanation (diagnosis) fully explained what was happening and she was left with many questions. Fern found it then and still now a struggle to maintain her flexibility and strength in these areas and that her dancing has “become dictated by the sensitivity of [her] leg and abdominal muscles”. She noted that the discovery of the
Alexander technique was a “silver lining” of having these injuries and the benefit that it has had on her psychological, emotional, physical well-being, has provided an “incredible 83 clarity and knowledge of body”. In addition to taking Alexander classes in college, Fern also saw a local physical therapist (the same office as for her peroneal tendon) for rehabilitation outside of school.
A more recent injury that Fern sustained was during her time working at an outdoors summer camp in the Pacific Northwest. She relates the occurrence of this injury with her mental state at the time:
This is also an injury related to mental health. My job was really hard and very
overwhelming and I had a complete lack of mental clarity...it was the first day and
I was [thinking that] things are going to be better, I am going to really work to
take care of myself. Twenty minutes later, I miss-stepped and my foot bent so fast
while I was on a trail in the woods and I [knew] I just broke my fifth metatarsal
because I have never experienced this pain and I have done a lot of things to my
feet and I know exactly what I just did.
Unknown to Fern until our interview, that fracture location is also known as a ‘dancer’s fracture’ and here was Fern, a dancer, sustaining a ‘dancers fracture’ from hiking - a fact that Fern responded to with the words “so fun, so fun”. She described the healing process as “being in a beautiful place with a beautiful community”; the summer camp changed her role to accommodate less walking obligations and she was able to go to an
Emergency Room the same day it happened. Some initial challenges she faced were waiting over two weeks two see an orthopedic physician for this injury after the initial
ER visit as well as the hassle of needing to ferry on and off the island her camp was on about 2 hours to-and-from each appointment. She tells me that on the day of our interview she can still feel a soreness at the site of injury, but that it comes and goes. 84
She is a strong believer in the interconnectivity of the body and feels that sometimes doctors have a tendency to not ask about related issues that could be in play.
She suggests that her doctors have more “big picture” conversations when examining dancers and other moving bodies. Moreover, she sees a problem with the strong relationship between physicians and selective pharmaceutical representatives. Her example to me was a period of time while at a conservatory where the primary medical director began prescribing the same anti-inflammatory medicine to many of the dance students. Through conversations with peers, the dancers found that many of them ended up with gastrointestinal issues, but obtaining an alternative medicine proved a challenge due to uncooperative communication and scheduling on the part of the provider’s office.
Recently, Fern is realizing that she would benefit to see a therapist in order to help cope with her mental health. She remembers hearing terrible stories in high school about seeing therapists which left a bad impression of the profession. She notes that in the past two years that narrative has flipped through conversations with peers and learning from their experiences. It is only recently that Fern is considering shopping for her own therapist.
Between ‘dance-specialists’ and non-dance specialists, Fern noted that she
“absolutely” notices a difference. She remarks on the same principle that she was speaking about earlier, that taking the time and getting the ‘big picture’ is more valued with dance-specialist. However, even some of the best dance-medicine doctors have fallen short of her expectations due to not spending enough time to listen to Fern’s questions and difficulty in scheduling. 85
Fern is able to uniquely identify that the conflict that a dancer experiences between being allowed to heal, and being pushed to perform, begins as early as in the classroom. She pointed out the difficulty and the lack of support that an injured dancer experiences while being enrolled in a dance class. She highlighted the predicament that dance teachers face when they encourage students to treat their injuries with time and appropriate healing methods while needing to assign a grade by the end of the semester.
This is a conundrum that we certainly did not solve in conversation.
86
Sam
New England, March 2017. I have known Sam for about a decade sharing the same alma mater and subset of dance and theater friends. At one time, I was in a piece he choreographed for a class, working with him for the better part of a semester accumulating to a single performance. I was pleased that he agreed to sit with me so that I could interview him for my research. I drove down to Connecticut on a dry cold day in
March and chatted with him over tea.
Sam identifies at the same caliber as an Olympic level athlete. He trains as such, dancing and touring 52 weeks a year within the United States and abroad. since graduating with his Bachelor’s of Art in Dance, Sam has been advancing within a modern company over the past seven years. From being the newest dancer in the company, Sam has grown to take on a dancer-manager hybrid role at the time of our interview. He detailed to me that in addition to dancing, his role includes “being a point person for development activities, all sort of administrative tasks, and work with casting decisions”.
Taking a step back, Sam reflected back in time and told me that his mom was a professional ballerina and when she stopped performing, she opened up a dance studio in
New Hampshire where she taught. He described to me his experience with a dance studio day-care, and explained that he started with moving and dancing at a young age, starting formal dance training around age 5 and then continuing dance through high school.
During this development, Sam “never thought [he] was going to be a professional dancer”. However, through his talent for the art form he was able to dance abroad after high school in Vienna, eventually returning to New Hampshire to dance with a full scholarship in the Theater and Dance department. From this opportunity, Sam danced 87 each summer at the American Dance Festival in North Carolina and at the end of his formal education, auditioned for his current company and was offered a full time position as a modern dancer.
When Sam was asked what the term ‘healthcare’ meant to him, he provided a broad definition calling it “a system of support” including all the formal and informal therapies a person could receive from a physician, mental health therapist, or Somatics practitioner. Moreover, he expressed that healthcare was a consistent consideration: saying that “healthcare is always on my mind because if you don't take care of yourself, small issues can turn in to big issues and big issues are problems conflicting with your ability to do your job”.
During his time as a dance student in college, Sam had an athletic trainer who was able to attend to his physical injuries and concerns for two years. He was referred to them through his own dance teachers and called the experience “eye opening” as this was the time he realized that “you didn't have to go to a hospital to get or a doctor's office to get care, it was like physical therapy”. Moreover, he explained that through receiving an evaluation, that he was able to learn about his body and took that knowledge and applied it in a way that was preventative or self-treatment for an existing injury. As a professional dancer, Sam has continued to expand his knowledge of his own body and taking care of himself. He described to me a double-edged sword of being a new dancer in a company:
“there is a big culture of passing along information [tips and techniques] to new dancers which is of course a little dangerous if you don't know the source”.
Knowledge aside, Sam detailed a few significant injuries during his dancing career, each with long-term consequences and learning opportunities. During Sam’s first 88 year as a professional dancer, Sam and his peers had a 30-show performance schedule in
New York City. Throughout this run, Sam sustained a neck muscular strain that ended up affecting him over two years. For the initial treatment he shared that he “just took Advil and kept going and got some massage therapy for it and that sort of thing, but wasn't really taking care of [himself] in a way that [he] now understand[s] how to”. The initial treatment didn’t foster a solid healing foundation and he found himself in continuing pain two, three weeks later. The management ended up lasting about six months as he took time away from dance multiple times to heal in conjunction with physical therapy, acupuncture, and massage therapy. He shared that from this experience, he developed, and has maintained, a self-care strengthening routine for the prevention of similar injuries.
About one year after his initial neck injury and rehabilitation, Sam sustained a second injury to his torso. During a Saturday performance, while three other dancers’ weight was on Sam, he heard loud snap noise (in our interview he clapped loudly to demonstrate) followed by searing pain and difficulty breathing. Not knowing what had happened and being the opening movement to the beginning of a two-hour performance,
Sam finished the show with continuous dancing including the lifting of fellow dancers. It was two days later, after flying across the country to get home, that Sam could see a dance-knowledgeable physician, be diagnosed with a rib dislocation, and have it relocated. However, after the follow-up to his rib dislocation, Sam was dissatisfied with the patient care attributing this to the physician’s unfamiliarity with his case which did not contribute to Sam feeling like he was being listened to. 89
Sam’s final of his more-significant injuries is actually recurring to this day. He has lower back muscular strains that come up for him once a year - mentioning that he can predict them and sometimes is able to defer them with proper preventative care such as with
Advil if he is scheduled to perform. Additionally, Sam has sustained toe fractures on two different occasions, each time, Sam was able to “dance through” by dancing barefoot and relying on the help of athletic tape.
For each of these injuries sustained during rehearsals and performance, Sam explained that Worker’s Compensation covered all expense and moreover, that Worker’s
Compensation is easier for him to use than his own insurance. On top of Worker’s
Compensation, Sam has never had a gap in subscribing to a health insurance policy. The types of preventative treatment he finds work well for him are not always covered:
The bulk of upkeep things that I pay for are acupuncture and physical therapy. My
[company] provides up to five paid appointments a year which is not a lot for
someone who is working their body forty to sixty hours a week, every week.
[After submitting] those receipts for reimbursement, beyond you are paying out-
of-pocket, and good body work is expensive so that's [my] biggest expense.
Sam finds that the primary barrier to seeking healthcare for him is the amount of time he spends in rehearsals and touring. With a rigorous touring schedule, he mentioned that he often has to rely on emergency rooms when he would prefer to be able to make an appointment with one of his trusted practitioners at home. In his own words “if I am only going to be home two days maybe, it's impossible [to seek care], if they don't have an appointment during those two days I end up having to go to the emergency room. And that's just been absolutely terrible, if I never went to an emergency room ever again it 90 would be great”. Addressing this problem, through his years of touring and being on the road, Sam has been able to identify key practitioners in certain cities.
Outside of the time constraints that Sam identifies as a barrier to seeing a practitioner is finding a practitioner that he feels is a good communicator and properly recognizes the physical demands of his work. Because his company does not have an in- house practitioner of any kind, Sam travels to seek help in New York City. The following two quotes detail what Sam found repeatedly when finding a practitioner:
the experience that I have had with many chiropractors is it seems like they are
reading the newspaper while you are telling them what is going on in your body;
then when you are done they are like ....cool, and they put down their newspaper,
crack your neck, and send you.
Sam expressed this sentiment numerous times when recounting interactions with various kinds of practitioners, but focused on medical physicians, chiropractors, and physical therapists as those that he’s found more ‘bodyworkers’ that he feels better with.
He expresses frustration when speaking about a second issue; being an elite athletic dancer and finding a practitioner that treats him at an appropriate level:
The support that I have access to doesn't seem like it’s designed to support
someone at my physical level. I go in injured and I am in pain, but I can do every
exercise that they know [of] they say “I don't really know if you are injured
[because] technically you can do these things.
Sam feels that he is performing at an Olympic athletic level, which makes him an anomaly amongst the general population patients. Of the practitioners that he has regular access to, he noted that “they are trying to help people who have desk jobs be able to 91 walk around the office”. Sam notes that his two main barriers to receiving quality healthcare are his year-round touring schedule and not being understood for the level of athleticism he exerts.
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Jade
New York, March 2017. Jade contacted me about this project through a Facebook advertisement that a Boston dance organization had posted on my behalf. We met at the end of March in New York City on a warm-for-winter kind of day. Having rented a meeting room, we had a nice view from high up of a dance company practicing in an adjacent building across the street. Jade was very friendly and we got on well during the interview.
Jade is a freelance artist and has been for 16 years and somewhat jokingly said she “creates life as [she] goes” through contract-based work. Her dance training began in dance competition studios but she figured out while she was still young that competitions were not for her. Ultimately, she went on to school and earned her Bachelor’s of Fine
Arts degree in Dance and Performance. She then earned her Master’s degree in Arts
Management in London; she lived in London for two years before “tragically” moving back to Boston.
The majority of Jade’s time as a freelance dance artist has been spent between
Boston (10 years) and New York City (10 years) with several years overlapping when she danced in both. She detailed how as a freelance artist, she piecemealed contracts together between multiple companies. At the time of our interview, she noted that she has good relationships with six different companies that she is or has worked with in New York.
She told me that as she is “aging out” she doesn’t audition anymore; both because “that’s not how [she] wants to spend her time” but also word-of-mouth is key and typically companies hire her through her known talent. She dances primarily in the contemporary and modern genres with a “fair amount” of Middle-Eastern work (belly dance) and some 93 musical theater. Her primary income is from dance and managing a dance studio, but she also supplements her income by moonlighting at a bar.
When I inquired as to her health network in New York, she responded that
Planned Parenthood “is pretty much it” for her and moreover that without them she would “probably be dead”; Planned Parenthood was responsible for finding cancerous cells during a routine examination and provided the services to help her through the process of removal. In addition, she favors clinics with sliding scale payment methods to also be a facilitating factor when she seeks care. Moreover, Jade relies on asking friends for recommendations when it comes to finding trusted practitioners. To find new contact lenses, Jade told me she just googled the closest eye doctor to her. She does feel secure in knowing that if she sustained a dance injury that she could go to the Harkness Center for
Dance Injuries in Manhattan; however, she is less certain about how payment would work without having insurance. I asked her about Worker’s Compensation insurance from her past or present dance company affiliates and she quickly answered that she has never been offered any kind of insurance when doing contract-based freelance work. She went on to express that she’s “never been a fan of the medical profession” and this feeling contributes to her hesitation to purchase medical insurance.
Thinking about accidents and injuries, Jade considers herself extraordinarily lucky in terms of dance related injuries having only sustained two that required stepping back from dance for a bit. The first was piriformis syndrome on her right side in 2005-2006. In her story, the recovery process was not remarkable but accessing physical therapy was the real challenge. 94
Being a Massachusetts resident at the time, Jade qualified for “Romney Care” or
“Commonwealth Care” depending who you asked. However, at the time Jade worked a single odd job for an arts company in Boston and the state insurance office confused a once-occurring job with a normal paycheck and marked Jade as making too much money to qualify further. This blocked her from affording the physical therapy she needed until she contacted a lawyer who specialized in defending artists. This artist advocacy lawyer ended up taking Jade’s case to court and winning - helping other freelance artists have a means to share freelance income as a separate category from part-time employment.
From this case, she was able to afford health insurance from the government-supported marketplace for the first time just two months before our interview “last month is when I first had health insurance as an adult”. Jade shared with me that the piriformis syndrome has not since returned.
More recently in Jade’s timeline, was a traumatic rupture of her right triceps surae complex (right calf). This injury occurred in 2013-2104; Jade said that she felt a “tweak” several days earlier, but when it tore it felt “like someone clubbed [her] in the calf’ or was
“Nancy Kerriganed” as she put it. This happened during a dress rehearsal the night before a performance and she had to drag herself off stage. She attributes the injury to her natural deficiencies and her own anatomy that predisposed her in conjunction with heavy plié work at the time. The immediate care she received was a wrap with an ice bag, followed by being driven home, and a break from performance the next day. Reflecting on the work, Jade recalled that the company she was with re-choreographed the show in
24 hours without her role. The next morning, she went to an urgent care clinic where she had an x-ray taken and was given a boot and crutches before attending the performance 95 as an audience member. At this time Jade began to reach out to the only dance-specific physicians that she knew of in her city and expressed to me that it was a large hassle in her life getting an appointment. From her experiences, she told me that waiting times and access to appointments were the largest barriers for her receiving care. She never pursued the company to help her pay for the rehabilitation, telling me that that those small companies are not able to afford that. After many phone calls and ultimately six to seven weeks later, she was able to see an orthopedic physician to evaluate her leg and told me that this evaluation was painful and that the physician was “a bit of a butcher”. However, she reflected that the physical therapists she worked with during her recovery for 12 weeks were fantastic clinicians. Lately and unlike the piriformis, she told me she has to be “on the lookout” when it comes to prevention of her calf being re-injured. As Jade had stated, for a career bounding between many genres and physical expectations, she is fortunate to have sustained only two isolated injuries.
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Zoe
New England, March 2017. Zoe was one of the few dancers I interviewed that I had the opportunity to see dance after our interview. I met her in March in a time slotted between her teaching a master class to a group of undergraduate dance students and her pre-performance meal. Zoe is currently dancing in and managing her own co-owned duo contemporary dance company that employs a unique guest-choreographer model, this was the company with which she was performing that evening.
Zoe’s development as a dancer stems from classical training which temporarily halted at the age of 13. At this time her dance teacher proposed an ultimatum: either dance every day to gain the strength needed to safely being dancing en pointe, or stop dancing. Choosing not to dance, Zoe began engaging with other athletic endeavors such as horseback riding, lacrosse, field hockey, track, and diving. During high school, Zoe began to dance again but a contemporary style; at which time she did not have the aspiration to be a professional dancer planning instead to study International Relations in college. She remarks that the goal to not be a professional dancer stemmed from a slight rebellion as both her parents had been professional performers and artists. Zoe remarked
“I just felt strongly that I was like “nope”, I love doing this but this is not what I, "do".”
However, she continued to be involved in dance and theater equally throughout her time in college. Also in college, Zoe spoke of two major life events: One, was a total anterior cruciate ligament (ACL) reconstruction at the age of nineteen, and the other was the bearing and birth of her first child during her senior year.
After graduation, Zoe and her family moved to Rhode Island, she married and had a second child at the age of 23. During the children’s younger years, Zoe had a few 97 different jobs such as in arts administration, design, and food service. However, recognizing that she is a kinesthetic person, she began performing again to “get moving.”
In her words: “I’m an athlete by nature and I need to be moving, I was not happy sitting at a desk, even if it was projects and organizations that I cared about, it didn't work for me”. This led Zoe to audition for an experimental theater company and she called this her gateway back into performing. Commenting on her style she remarked: “I'm very much a contemporary dancer in my contact practice and a contact dancer in my contemporary practice”. The transition into theater was eight years ago and since she has been teaching and guest lecturing at the college level for numerous colleges in America and once in
Finland as well as managing and dancing in the company she co-founded based in based in Providence, Rhode Island.
Zoe was quick to identify the importance of holistic care in her life saying: “I want doctors that are willing to look at the whole picture, the physical, mental, emotional,
[and] spiritual health”. Zoe noted that accessing practitioners has not been her struggle but interacting with insurance companies and finding good practitioners is the difficult part for her. Zoe commented that being insured has always been very important to her for several reasons including being a parent, having regular screenings, and having had a
“melanoma scare.” In a recent appointment, she discovered that she has active Lyme disease again, after a twelve-year hiatus. Zoe and her husband filed for divorce several years before our interview, but she remained on his insurance policy with their children for several years following. She is in the process of purchasing her own plan while her children remain on her ex-husband’s policy. Currently in her part-time roles as a teacher and guest lecturer, she is not eligible for benefits such as health insurance. Expressing 98 some frustration, Zoe remarked: “in my opinion, [it] means that I teach the same amount as the full-time faculty, but I don't get any of the benefits”. With regards to being insured under Obamacare, Zoe remarked “as an artist I don't make a lot so I have been able to qualify for tax credits and have to insure myself in a fairly affordable way”. When working towards getting coverage with Obamacare, Zoe expressed a long process of trial and error on different policies before, after several months, a customer service representative was able to sort her situation out.
Being a mother, Zoe reflected upon her time being pregnant and dancing at two different stages in her life. Her first was during her senior college year, Zoe danced through the eighth month saying “I danced all through my pregnancy. It was great”.
During her classes she said she received enormous support: “my teachers were great and they trusted that I knew my body and knew how to modify material and adjust”. She recalls less of her activity during her second child, noting that she was taking care of a toddler, but speculated that she was walking and practicing yoga at the time. For both pregnancies, Zoe chose to have a natural birth at home with a midwife rather than in a hospital with an obstetrician. She told me that her midwife said some encouraging words that stuck with Zoe: “if you come through the experience of natural childbirth, on the other side you will have this incredible sense of what your body is capable of doing and that's really good fuel for the physical challenges of parenting an infant and onward. You have this incredible sense of your strength and the capability of your body and your will.”
Revisiting her athlete body however, Zoe is not a stranger to some aches and pains. Being a dancer and athlete as consistently as she has had placed some wear and tear on her body. Her knee, as mentioned previously, had an ACL reconstruction in her 99 early college years. She notes now, she has arthritis in that knee and would like to have an arthroscopic surgery in the coming months to clear out debris in hopes of avoiding a knee replacement. She spoke more of the further complications: “the one that had the
ACL reconstruction...everything is wrong with it. I have a Bakers Cyst and bone spurs, three tears in the meniscus and my patella is misplaced; my QL is 30% weaker so my quad is significantly weaker”. To manage her knee issues, Zoe dances with a knee pad and sometimes an additional neoprene sleeve while taking ibuprofen and attending physical therapy when she can.
Moving away from musculoskeletal injuries, Zoe has twice been diagnosed with
Lyme disease. Like many people with Lyme disease, Zoe had a difficulty getting diagnosed each time. In her case, the conditions presents as several unrelated aches and pain such as temporomandibular joint (TMJ) pain, shoulder pain, and accentuated knee pain. Moreover, she has had two cases of cancerous cells with a “melanoma scare” and a procedure to remove cancerous cervical cells caused by human papillomavirus. Finally,
Zoe is currently dancing with an old foot stress fracture caused by accentuated bunions on her left foot noting that some of her foot pain if from past injuries transforming into arthritis. She further noted:
I take a hot bath every night with Epsom salts like, I am a thirty six year old, very
hard working body with a lot of old injuries, I hurt, it takes me a really long time
to get warm, you know, I have to take anti-inflammatories and again I don't know
how much of this is the Lyme Disease and how much is history. 100
Even with the recent re-diagnosis of Lyme Disease, Zoe expressed that she felt confident in the treatment and her prognosis to move past the aches and pain. She continues to dance in her company and teach in the New England area.
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Olivia
New York, April 2017. I came into contact with Olivia through my participant
Jade. Olivia and I started making plans in March and settled on late April in New York
City to meet. I rented a meeting room in New York which had a lovely view from high up in Manhattan.
Originally from Indiana, Olivia began dancing at the age of 6 with ballet and continued this training through a performing arts high school in Eastern Massachusetts.
After majoring in ballet in high-school, she returned to Indiana to attend university and majored in classical ballet performance while simultaneously earning her Pilates instructor certification. Post-college, Olivia danced for a famous New York company until she was injured two years prior to our interview and has been freelancing ever since her rehabilitation.
In becoming a freelance dancer, Olivia detailed to me the handful of times she has taken classes in a style such as improvisation or tap dance to fulfill a part she was casted for. She spoke happily of her expanding repertoire and that exploring new forms was keeping her reactions to choreography from falling flat. A second note on her freelance career was that, due to her tall height, she was often typecast for jazz roles rather than ballet roles as such in roles like “An American in Paris”.
Being in her late twenties, Olivia has been ineligible for her parent’s health insurance for almost two years at the time of this interview. She described her parents to me as “hippy-types” in the respect that they lean more on natural remedies than being particularly doctor-visit-heavy, and Olivia has seemingly carried this sentiment. At the time of the interview, Olivia was insured under the New York State version of 102
Obamacare and had previously been under her parent’s plan. This transition was only interrupted by a few weeks due to paperwork and processing. Olivia has the specific malady of Celiac disease which is a gastrointestinal condition which was diagnosed during her senior year in high-school. Olivia noted that many of her immediate family members have gastrointestinal issues, which she says may have contributed to her late diagnosis as she didn’t realize her symptoms were abnormal.
During her first month at the performing-arts high school, Olivia underwent an ankle surgery. Post-surgery, Oliva reflected that being away from home, not being able to dance, beginning taking birth control pills, and access to a large cafeteria were factors that contributed to her weight gain and subsequent diet restrictions. Compounded with her diet restrictions, Olivia described suffering from severe mood swings and episodes of lightheadedness. Her eating restriction ended when she was selected to be in the school’s dance company, at which point she began reintroducing foods into her diet such as rice and toast. It was at this point that she described to me was “the perfect storm” that triggered her Celiac disease.
After some advice from the school’s health center, through an elimination diet
Olivia discovered that gluten was the culprit to her wide-spread pain, migraines, dizziness, and gastrointestinal issues. From this personal discovery, she refuted the procedure to be formally diagnosed because that process involved ingesting gluten again to take a blood sample; at this point in the interview she told me to this day she is unwilling to reintroduce gluten into her diet because of the physical symptoms it causes.
Olivia reflected on her experience of having undiagnosed Celiac disease and dancing: 103
If you are always bloated and always cramping you can’t hold your stomach in
you can't hold in the right position, you don't look right and you are in a lot of
pain. I remember my knees [were] such an issue in high school, my knees always
hurt and were always swelling, everything hurt.
Since this diagnosis, Olivia is careful with her sensitive gut by limiting dairy and eliminating gluten. She noted that her Celiac disease sometimes manifests into a depression that she is managing with prescribed antidepressant medication.
As previously stated, Olivia does have coverage under New York State’s ‘Obama
Care’ program; she told me she pays about “20 bucks a month” and that her current plan is the third one she has tried in a year and a half of purchasing her own insurance.
Olivia’s out-of-pocket expenses have included once-a-year dentist visits, an acupuncturist, a massage therapist, and any time she sees her gastro-endocrinologist who she treats like a general practitioner and trusts for prescriptions. She remarked that seeing her assigned primary care physician, (assigned by the insurer) was a challenge due to waiting times, and that in fact she has never actually gone to see them.
Olivia took me through her injury history from toes to head-literally. In her time as a professional ballet dancer and freelance dancer, she has sustained: bunions, inflamed bursae (feet), lax ligaments of the anterior ankle, second metatarsal stress fracture (during a full Nutcracker season), Os Trigonum (ankle fracture), Talus bone spur, tendonitis,
Osgood Schlatter’s, bilateral knee chondromalacia, bilateral hamstring strains, a subluxation of the patella, snapping hip syndrome, an anterior translation of a lumbar vertebrae, multiple shoulder dislocations, and to finish this list, temporomandibular joint dysfunction. 104
With this short list of injuries, Olivia has had two surgeries, one on each ankle, the first being at the age of 17 (left) and the other during her freshman year of college
(the other ankle). The first, at 17, was to remove shattered pieces of her Os Trigonum from her ankle. She has sustained the injury from jumping out of a tree when she was 12; six years a dancer Olivia already knew this may turn into an issue for her dancing. She told me at that time the physicians she saw after the fall were not dance doctors and didn’t identify the long-term problems this accessory bone would cause in her profession.
Between this injury and her surgery five years later, Olivia told me that she “thought pointe work was supposed to hurt like that because our teachers said it was gonna hurt, it was just gonna hurt.” The surgery that did occur five years later, Olivia described to me as “so not good” and the following rehabilitation as “miserable” partially placing blame on an orthopedic-surgeon intern that performed the surgery and not the prestigious dance- specialist surgeon she intended to have operate on her.
The second surgery occurred when Olivia was 23 came after a season of
Nutcracker in which she was performing the principle role in her second year with the company. With the desire to prove herself, Olivia habitually practiced her pointe work in and out of class; however, her the tendons of her ankles were rolling over a bone spur so often that they became painful and audible. She told me that at the time the director was quite “brutal” and as a result she did not share her pain with this person with one exception where the outcome was being pulled from the following show. There was no in-house physical therapy at this company much like Olivia was used to being at her performing arts high school; moreover, seeing a physical therapist during a season was “a very touchy thing” in Olivia’s words. Once the Winter season ended, Olivia was not cast 105 in the same level role as previously, but was responsible for demonstrating during rehearsals. It was at this time when she went up for a turn, fell, and subsequently was unable to “un-pointe” her foot. Prompting her to return home in the coming week, a vacation week, she saw an orthopedic surgeon covered under her parent’s health insurance and scheduled the surgery for three weeks later. Olivia recalled that at this point the pain was so severe that walking up and down stairs proved challenging. Just two weeks after this surgery, a booted Olivia drove herself back to her residence, 10 hours away to return to work. Her rehabilitation was a combination of Pilates, physical therapy, and her own return-to-dance plans that her surgeon discussed with her. After returning to dance classes six weeks after her surgery, she was informed by her director that she would not have a contract with that company for the coming year.
Since leaving the ballet company, Olivia has been a freelance contract-based dancer in New York City. She noted to me that she feels like she is in the final third of her dance career, after dancing professionally for about 10 years and beginning this freelance journey, Olivia feels that she will be pickier about the physicality of the future contracts she takes. On a final note, I must include that 2017 was “the year of the hip flexor” for Olivia as she feels that each year one part of her body becomes the squeaky wheel and at the time of our interview, her hip flexor was that wheel.
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Benjamin
New England, April 2017. Benjamin is a semi-retired professional dancer. Semi- because he is currently active in performing renaissance dance reenactments as part of his role as a dance historian and director of his own Baroque Dance company. He also has part-time employment at a Boston institution of higher education and teaches at summer dance and music workshops in the United States and abroad as well as dance classes in the Boston-area. His spouse and daughter are both also dancers. We met for our interview in April of 2017 in a meeting room at his Boston institution. Benjamin heard about my research a month earlier from an advert posted from a local dance-advocacy agency.
Benjamin’s education began as a double major in art and math in a Chicago university. He left this program to pursue dance, noting that he came to dance “late” because it was around this time that he began training in ballet and contemporary forms.
After college, he continued on as a contemporary dancer for several dance companies freelancing between New York City and Paris. Beginning in NYC, he continued to study under a prestigious dance scholarship and from there began shifting focus to early, renaissance dance, and dance history. Benjamin traveled back and forth between New
York and Paris in the early 80s, performing both contemporary and late-Renaissance and
Baroque works. Moreover, he performed late-Renaissance and Baroque dance in
America, Canada, and France. He continued as a full time freelance dancer throughout the 80s until 1992 when he moved to Boston with his partner and began a part time job at a Boston educational institution.
Benjamin notes that before beginning his current part-time position in Boston, he was earning his living as a dancer but “it wasn’t much of a living”. When thinking about 107 healthcare, Benjamin relates this to health insurance and notes that this was a reason he married his current partner. His part-time position allots him health insurance and when he was hired 25 years ago, he married his spouse, also a Baroque dancer, to transfer those spousal benefits to her.
Benjamin says currently he is thinking about dance almost daily because his daughter is managing an injury and he is actively involved in helping her find care. He frames healthcare in the context as the process for taking care of the equipment he uses for dancing. He did not have health insurance during most of his dancing career, before moving to Boston. During these periods of without insurance, Benjamin said he would
“tough it out” and do his best to aid his ailments with over the counter medicines and self-treatment. Even in Paris where they had a comprehensive system, he was not able to navigate the system well and in one anecdote, ended up receiving a non-diagnosis from one clinician (type unknown) and continuing to deal with the pain on his own. Benjamin notes that while in Paris, his idea of treatment was taking some time to rest the affected body part - not to seek external medical help.
When employed part-time in Boston, he began receiving health insurance benefits as a part of the remuneration package. However, Benjamin noted that even navigating this system was difficult as a dancer. This current system includes on-site physicians and physical therapists, however, Benjamin tributes his difficulties to the provided clinicians not being dance specific and ultimately not the right fit for his dancing body. It took him time to build a dance-specific medical network that he now feels secure in going to in times of injury. He said he found the first physical therapist in this network through his daughter’s ballet teacher. Once he found one dance-specific clinician, his story moves 108 through a series of personal and professional referrals until he made several good connections. He notes this process took years to really accomplish. From our interview, it feels that Benjamin places a good deal of trust in these clinicians and can communicate with them well. His only question is how well his aging-dancer body is matched with the dance-specific services of the physical therapists he’s worked with. These issues are compared to the issues of absence of a medical network he felt in New York when he lived there for ten years.
Thinking about what Benjamin wants to see change in healthcare delivery would be more preventative treatment. He also refers to what he would like as preemptive treatment. In thinking more about a current calf injury, he is nursing, he feels it would be ideal to be able to bill insurance for treatments before a diagnosis has to be made.
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Coral
New York, April 2017. Coral is a dancer who is currently teaching at a private high school about a 2-hour train ride North of New York City. I met with her one day in
April of 2017 after her classes had ended for the day. Her story began with a short stint in ballet as a three-year-old, after which she returned to dance at age seven when her parents placed her in Irish dance. Her parents were involved with some Irish organizations, so by the time she was nine years old, Coral found herself on tour as an Irish dancer. Her Irish dance teacher was a college student who moonlighted teaching dance and from whom
Coral ended up learning for many years. Through Coral’s stories, I drew a conclusion that she had little resistance in pursuing Irish dance due to her natural affinity and talent for the genre. However, When Coral entered high school she stepped away from touring and instead of dancing strictly Irish dance ventured into some contemporary and modern classes.
This transition to a modern and contemporary genre reinvested her interest and allowed her to decide that she wanted to remain in the ‘dance world’. Coral earned her bachelor's degree as a full-time student in Communication and Psychology. The transition into contemporary dance lead to a slew of more training under multiple dance companies and professional dancers. Ultimately, Coral and a friend founded their own project-based, dance arts organization in New York City. In time, this company expanded to be a school with over 100 students enrolled between the ages of three and twenty-five.
In addition to running this company, Coral is still a part of the original Irish dance company which tours internationally and she continues to teach dance full-time at a private high-school. 110
Moving into our conversation about healthcare, Coral quickly stated that she does not think positively of traditional Western medicine; pharmaceuticals, the idea of large- corporate companies, and medical doctors. Notably, she remembers that she has never had a doctor who remembered her the next time she visited and moreover, her experience with physicians who were experts in their field have not proven effective with her either.
Coral elaborates by saying she often does not feel heard by many clinicians and has had to “pull teeth” to get some doctors to forward medical records and engage in communication between offices.
Coral equates taking care of her dancing body as taking care of the tool of her trade. When seeking medical attention, Coral opts for more holistic practices contrary to the “typical American model”. Coral has a chiropractor in her hometown in New York whom she has been seeing for over ten years. This chiropractor has acted as a primary care in that they take action to manage Coral’s referral needs. Coral calls her chiropractor
‘the coordinator’ and is “the bomb, a rockstar” for having gone above and beyond by taking upon this keystone role. All of the practitioners she now goes to (craniosacral, massage, and acupuncture, and the chiropractor) own an individual private practice and have been pieced together through this referral process or dancer-to-dancer recommendations from Coral’s dance peers.
Specifically speaking about health insurance, Coral has had communication difficulties in the past. Coral has been on her “parent’s MVP health insurance” plan for her whole life with legislation in New York allowing her to remain on their plan until age
29. Remarking on her experiences interacting with her insurance company, Coral expressed that the coverage and accessing services feels so confusing that she jokes that a 111 health insurance lawyer would be necessary to really understand what she is purchasing.
When seeking physical therapy, Coral would rather her physical therapist deal with talking to the insurance company. She has had experiences where she felt she received conflicting or incomplete information and theorizes that insurance companies make the process so complicated to avoid fulfilling claims for services.
Another healthcare frustration that Coral mentioned had to do with communication between medical offices, specifically a physical therapist and orthopedist when she was in the middle of a rehabilitation program for her ankle. The physical therapist was told one thing (that Coral has used all of her covered visits) but the truth was another (that she had many covered visits remaining). This error of communication between two different offices led to several appointment cancellations and ultimately stress and an interruption in Coral’s rehabilitation program. Between the perceived hassle of seeking care for typical illness and wanting to “get on” with life, Coral finds that healthcare is moving towards a more alternative medicine, alternative practice foundation. She noted that her own physician uses and can bill for acupuncture as evidence of this.
As a teacher, Coral reflected upon how as a young dancer she was taught to “push through the pain” when she was dancing. This behavior was reexamined and ultimately changed when she became responsible for young dancers as a part of her dance arts organization. These days, Coral focuses on examining pain to determine a course of action. Without formal training in anatomy or rehabilitation skills, Coral has picked up the majority of the knowledge that she passes to young dancers through her own injury rehabilitation experiences with holistic practitioners mentioned above. Moreover, with 112 her experiential applicable knowledge and having young dancers to look after, Coral notes this ‘lit a fire’ under her to do more personal research to enhance her teaching practice. With pride, she relayed to me that she and her company try to “promote rest, taking injuries really seriously, and to celebrate that”.
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Quinn
New York, May 2017. I met Quinn through a personal contact that was employed at the same school that she is a teacher for. Because of the timing, we could not make an in-person interview a reality, so settled on being my first online video interview.
Quinn began dance training at the age of 17; beforehand she did gymnastics and other dance-associated activities in Oklahoma City, where she is originally from. She attended college in Missouri and earned a Bachelor’s of Fine Art in Dance and a second
Bachelor’s degree in Electronic Media. Post college she began the audition process including theater summer stock programs. Additionally, Quinn worked in regional theaters and a cruise ship before moving to New York to continue pursuing work as a performer. At the time of our interview, Quinn had been working in New York City for
30 years. A majority of her career in the city has been as a performer on Broadway, a dancer in a premiere nationally touring show troupe, and an actor, appearing on television, and in popular musical-adaptations in film. In her current position, Quinn holds dual roles as both an actor and as a musical theater and jazz dance instructor in
New York City. Noting that she came to dance late compared to some of her peers, her excitement for being a performer and entertainer came through during her interview saying: “I just love it so much, it's just fun, you accomplish something and I love the idea that as a team we can work together we can make this thing and entertain people”.
During the time of our meeting, the national news cycle was heavily focused on and amplifying the issue of healthcare in the United States. When I asked Quinn about healthcare she quickly responded that it was “clearly an issue” and that it comes up for her in times of pain and injury. During out interview, Quinn was in a period of 114 experiencing chronic lower back pain which she relates to two previous female reproductive related surgeries she had three years prior. She noted that after her surgeries where “they took everything out” and she began feeling more back pain, theorizing that some of the compression from her internal organs may have been previously alleviating some of her back pain. She reflected that her current pain, which is sometimes classified as sciatica, feels “unmanageable” as she has been seeking treatment from a chiropractor and her husband, a bodily therapist, for years. Two weeks after our interview Quinn was scheduled to have a third surgery to alleviate the pressure on the nerves; she was nervous for surgery but had hopes for the potential pain alleviation.
Having a long Broadway career, Quinn is able to tell a variety of tales of on-stage injuries she had managed. For one, during a Broadway performance Quinn strained her hamstring to a severity where she heard an audible snap upon occurrence; “I had to sing and I am feeling cold and hot on the back of my hamstring, [thinking] well this sounds bad, and then as I am processing it and still trying to sing and be in character, I have to do a cartwheel and land on my knee and I was like ‘oh shit’”. Quinn expressed that many of her injuries including her torn hamstring, were due to her natural flexibility and strength combined with a lack of controlled training behind her movement. She was able to
“muscle her way into” positions and place her body at risk for injury. She relates this to the fact that she started dance training later in her development at the age of 17. Being in a Broadway show, Quinn gave her hamstring time to rest during the days and saw a physical therapist to aid healing, but ultimately she was still dancing most nights for the nine months it took to fully heal (with numerous re-strains along the way). Because it was 115 a performance injury, Quinn noted that it was the show’s company that paid for her physical therapy appointments.
In another instance of a dance injury, Quinn was auditioning for a show and performing some complicated steps “with a jump in the air and then a move, jump, turn, move, jump” Quinn remembered a move too late, and this mistimed jump led to an imperfect landing, which “tweaked” her knee. She said that by the time she had gotten home her knee had noticeably swollen to “the size of a football”. She received a callback, was hired, and claimed the injury happened once she had the job. Uninsured at the time, this again allowed her to get her physical therapy visits paid for by the show’s company.
It turned out, according to the physical therapist’s assessment, she has subluxated her patella and had a weak IT band. She called this experience her “first awakening” into adulthood, saying “Oh that's why you need a doctor, that's why you need insurance,
‘cause there may be times when you are not hired [and still] get hurt”.
The final story of an on-stage misstep again occurred to her knee:
I had another one where I ran into a steel set piece because “the stage was very
funky and they put the girls in DocMartens so it was extra sticky...I hit [a pipe]
and I was like “oh boy”; I was very lucky it did not crack my patella, it felt bad
enough. I was out for like two weeks.
For all three of these instances, Quinn verified that she had seen a medical doctor, each time paid for by the show’s company. Moreover, in all three instances she was referred to a physical therapist and would only pay money if she needed more appointments than were allotted per injury by the insurance policy. She noted that at the time she felt spoiled paying “under $200 every quarter for full health, full vision, and full dental”. 116
Quinn expressed that when she has had several interactions seeing physical therapists for her lower back and hips, finding that each can be a hit or miss. In one instance, Quinn had a one-time visit with a physical therapist because she felt that their prerogative was to place her “on the different pieces of machinery so they can check it off for their insurance and get paid”. On the contrary, another physical therapist she saw for the same pain patterns was initially dismissive of her complaints. Quinn said “she was a former dancer and had done a lot of modern dance and the more I saw her and the more I talked, then she started to recalibrate and understand what I was saying”. Quinn reflected that sometimes in these sessions, she had to fight to be heard comparing herself to typical patients “who were not athletes or dancers, so I did feel like I had to be very clear and keep reiterating that “okay, my leg goes up in the air, that's not my normal, this is my normal”. She found she would have less communication and understanding issues if the therapist was working for the show. Unfortunately, this particular physical therapist eventually left the practice and Quinn noted she didn't have the energy to “train” another practitioner to understand her needs. In a third experience, Quinn remarked that the physical therapist was “gifted from some other source than himself”, was a healer, and could tune into people's needs. However, this person was not business-minded, so often
Quinn felt, that the assistants that he would employ undermined his skill set by being inattentive.
A large contributing factor to Quinn’s healthcare is her spouse. Quinn’s husband is a therapist of several somatic and manual body work techniques, specifically muscle activation, personal training, and posturology. Concerning some of the chronic pain that
Quinn experiences in her low back and hips, her husband is her main source of treatment. 117
Another supportive factor is Quinn’s connections to, and knowledge of, groups like the Screen Actor’s Guild and The Actor’s Fund. For example, she spoke positively of the organization ‘Career Transitions for Dancers’ which had been absorbed by the
Actor’s Fund saying they started “a support group for dancers specifically dealing with injuries that they had that changed their trajectory; a safe place to talk to each other...a nice place to talk to someone who understands your world and where you are coming from”. She also described the Actor’s Fund, which operates a clinic that offers fees on a sliding scale or potentially even fee-free for union members, being a facilitating factor for her and her peers accessing healthcare.
When Quinn stopped performing on Broadway full-time, she was able to contact the Actor’s Fund for guidance in purchasing her own insurance - they are also a health insurance broker agency that specializes in helping performers. For several years since,
Quinn and her husband have managed buying their own health insurance as freelancers.
In speaking about insurance, Quinn expressed that she wished insurance companies would make their terms and conditions easier to understand and offered a local customer service support saying “because someone in California doesn't know what [is going on] and they make it more complicated than it needs to be”.
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Piper
New South Wales, June 2017. I contacted Piper through my research affiliation in
Sydney, she was the first Australian dancer I met with in late June. Piper was a special interviewee for me to meet because in beginning this project I was very curious about the experiences of mothers who dance, and Piper was pregnant at the time of our interview.
Moreover, she was my first Australian interviewee. I must add that through Piper I learned of the smallness of the Sydney dance “scene” because I had plans to go to the same small dance performance that Piper was going to attend the night of our interview meeting.
Piper is an independent contemporary dancer and “typically” will do about ten to fifteen different dance projects (contracts) a year. Starting with ballet and jazz, Piper continued her dance training to focus on contemporary dance. She completed three years of university study in Sydney and since graduating, she has been a freelance artist; her future roles are unknown and are thus impossible to physically plan for so she could not describe for me a typical physical workload. She described her recent contracts and told me she’s gone from three weeks with no work where she maintained her physicality with yoga and swimming, transitioned into soccer-training as part of a project, then moved into a “floor-based, rolling, soft” technique piece, and very recently an aerial project.
Piper has never been part of a full-time company, she’s been an independent artist since she graduated from her three year university program about thirteen years prior to our interview. In terms of consistency, Piper told me that the latter six years have been consistent, always on-and-off, but consistent compared to the first several years out of 119 school. She stated as she is “hitting mid-thirties and becoming an older dancer” that healthcare is becoming a topic she engages with a bit more consistently.
When I asked Piper about any dance-stopping injuries, she replied that she has
“been lucky not to have had anything serious”. However, a year and a half ago, she tore her rectus femoris - taking 3 months off from dancing. The pain of her rectus femoris began six months prior to a particular piece that the company she was working with had three-weeks to choreograph a work for performance. Piper described that work as “not particularly physical” and therefore, she felt she was safe to keep harboring her anterior thigh pain. During rehearsals, her pain was continuously being exacerbated and at that point, she sought out care from an osteopath who flagged that this could be “something much more serious and to chill out”. She “sort of did” - she was still working through the contact - and during that time, she felt that she could “tailor the movement to be a little more chilled out”.
Unfortunately, this failed as Piper described feeling a painful “pop” sensation during a rehearsal and went back to the osteopath who referred her to a sports medicine physician. Several images later (x-ray, MRI), it was determined that piper had damage to her rectus femoris, although Piper’s memory of the exact diagnosis is forgotten, it was then proposed to have a platelet-rich plasma injection at the site of the injury, but ultimately Piper decided to rely on total rest for three months. It was at this time, that the
“aging dancer body” was brought up to her and that this injury may become something to manage long-term. When I asked her about how she felt about the intervention and medical care she received, she reflected that even now she doesn't feel 100% confident in what the injury exactly was and that the osteopath wasn’t clear about the severity. She 120 says that today the area feels completely healed. During her three months of not dancing, she was hired by a company she had worked for in the past in an administrative role so she was able to continue working in that capacity while she recovered.
For her rectus femoris injury, because she was harboring it for six months and through multiple contracts, she couldn’t attribute it to a particular company and didn’t file for WorkCover. She said it never came up between her and her employers at the time. In terms of payment, Piper does not purchase private health insurance but is instead solely insured by the public Medicare system. Throughout the nine-month process of sustaining and healing from her rectus femoris injury, she paid out about $2,000 for out-of-pocket consultations - receiving partial reimbursement. She told me that “if [she] pursued it, could have gotten a larger portion back”, but also stated that the imaging tests were free under Medicare. Overall, Piper told me that as an Australian citizen, she feels supported in terms of healthcare insurance and getting treatment for free, but as a dancer specifically, she does not feel supported.
One other injury Piper detailed to me was from 2003/2004, before her rectus femoris injury; Piper heard a loud snap or clunk noise in her knee and didn’t seek medical attention for it at the time. She notes that she was swept up in a project and didn’t want to take time off. She “battled on” and noted that she’s had issues with that knee ever since.
She danced in pain and says she doesn’t think she did any sort of home treatment for her knee. At this point, she is aware that that knee is “something to look after” and during physical projects, she’ll place extra attention and physical training to that knee. Piper has never had the need for a surgery, but suffers from various “knee things” and feels her right knee may benefit from a sort of an intervention in the future. 121
During our interview, Piper was 6-months pregnant with her first child. She told me that she made the decision to stop dancing about three weeks prior as she completed a three-week project in which she wasn’t learning choreography, she was creating it and exploring movement with a small company led by two women. Piper continued:
it was quite doable for the three weeks but at the end of the three weeks I had a
very strong sense that that was enough dancing...I trust my body so much, I don't
have to think about it, I don't have to look after it. Because it was creative
development time, it was making and creating a show, that process became kind
of frustrating because I didn't feel free in the body that I would usually work with
to be creative.
Since stopping dancing, Piper had been working with yoga and told me she plans on attending classes and is “happy to keep finding what [she] can and can't do and what feels ok and certainly don't want to stop moving”. Similar to her feelings of not being understood and heard about her rectus femoris injury, Piper expressed a similar sentiment early on in her pregnancy when she sought out advice from her physician when they would say “you’ll be fine:” She felt frustrated that she couldn’t feel confident that the physician understood the ways in which she was using her muscles, particularly her pelvic floor and moreover frustrated that the feedback she was receiving was not clear.
She describes her self-care and injury-management routine to have grown and adapted with her dance career. She noted to me that between Workers Compensation and public health insurance, her preferred treatment is to see a 1. physiotherapist or 2. osteopath. To clarify what a osteopath was, Piper expressed that they are similar to a chiropractor or an osteopathic physician, but also neither. When Piper was younger, she 122 expressed that she would “leave injuries often and not see someone to get proper treatment”. The growth she said came from more respect for rehabilitation and greater knowledge for what type of practitioner to see. Moreover, she also noted that money was a barrier that encouraged her to sit and wait on injuries longer earlier in her career. Her knowledge pertaining to whom to seek help from comes from her peers and dance colleagues/ teachers. Piper expressed that she has never had a single practitioner who she would trust with all of her physical advice, it’s more of a collection of people.
Because Piper’s contracts and repertoire are each unique and unrelated, her experience seeking out a physiotherapist - even a dance specific physiotherapist, has been difficult; she notes: “I find it very frustrating when I see people who go ‘Oh you are a dancer, we understand what you need’ and actually their vision is of a ballet dancer or a company dancer that have a particular physicality and facility that I don’t necessarily have.” She went on to note that finding a practitioner who can listen and understand her physical demands and adapt their practice to help her specifically, is rare. She continued to say “I haven't had many really great experiences with health practitioners. Quite often I feel like this conversation hasn't quite happened in a way I feel like that person really understands what I am [and] what I am doing”. She feels that her dance career will keep
“barreling on” and has plans to continue after the birth of her child.
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Alynn
Queensland, June 2017. Alynn and I could not meet in person for the time I was in Australia, so we made do chatting over an online video program. She recapped her dance development stating that she had grown up doing commercial dance and transitioned to contemporary dance when she was exposed to it in college. For college,
Alynn had moved clear across the country for a three year Bachelor’s program in dance.
She noted that during this transformative time, the dance program in Western Australia
“opened up my world and understanding of what dance could be”. In terms of her health, she feels that she learned a lot about injury prevention and injury management from the dance teachers during this program as well. She felt as though knowing her limits has improved since college, but began her professional career with a solid foundation.
Following graduation, she moved to New South Wales to continue pursuing a career in professional dance. During this developmental period, Alynn found herself dancing for companies in Tasmania, Adelaide, and Perth. Moreover, she worked with independent choreographers and did overseas touring including yoga workshops. Two and a half years ago, she was hired as a full-time dancer for a modern company in Eastern Australia where she is currently employed.
Being unfamiliar with Townsville, Alynn explained to me that this small-to- medium sized company was situated in a town with a population of 170,000 people and her experience of the local population is that most work in the army or are student marine-biologists. In terms of her healthcare, she finds that there is not a range of holistic care options available. She noted that she has not come across many practitioners that she has found to suit her needs or understand the specifics of her craft. For example, as her 124 company is small-to-medium, there are not under-studies for her role. Therefore, an injury need be managed rather than the dancer “shut-down”, a practice she finds most practitioners have a problem adapting to. For this reason, Alynn stated that she places more trust in practitioners with dancer-clients or dance background. Moreover, as a dancer, Alynn finds that the milieu of dance leans towards avoidance and self- management that she sees in her peers. Alynn relies heavily on personal referrals to find practitioners.
An example of self-management comes from an unfortunate memory of a meeting with a street curb the day of a dance performance while she was working as an independent artist in New South Wales. She notes that during this this she “felt reluctant to get treatment due to medical costs being high and income being low.” With a “puffy” and painful ankle, Alynn pushed through the performance because there were no under- studies. With no immediate treatment available, she made the choice to not seek medical attention; Alynn stated this injury took eight months to fully heal. For her continued practice, she noted that “it was just a matter of modifying for months” while she also iced, applied heat creams, and practiced patience. However, Alynn has sought medical attention for an injury in the past. She had a neck injury happen just two days before a show; again with no under-studies. She saw a physiotherapist who was an ex-circus performer, a quality she expressed was appreciated due to his professional proximity to performance. He was able to alleviate her pain quickly and she considers the treatment useful in that sense. The injury was diagnosed to be a neck strain which was further managed well after the performances were over. 125
Throughout her career, Alynn has seen multiple kinds of practitioners such as osteopaths and physiotherapists. She expressed disappointment in the lack of recognition, from her experience with practitioners, for a dancer’s knowledge of their own body.
During our conversation, Alynn admitted she does not know a lot about holistic practices, but she feels that a more holistic approach is what her body responds better to. She feels that doing a consistent yoga practice has been a stabilizer for injuries and a way of finding balance. Alynn’s current network relies on a massage therapist who is currently working on a nagging neck injury whose treatments have been very valuable. Also,
Alynn sees an osteopath if she is more acutely injured, but this person is not her
“favorite” practitioner. She notes that not having enough time is a barrier to her seeking or gaining care for pain or injury.
Reflecting upon the Australian health insurance system, Alynn is currently on a private healthcare service. She often feels like she is confused or unaware of healthcare policy and structure in Australia and that much of her health insurance information comes from friends and personal conversations. Moreover, because she has private health insurance and works for a company, she has double coverage meaning that she rarely needs to pay out-of-pocket with these two working together.
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Harper
New South Wales, July 2017. Harper is a dancer in the Sydney area that I met through a mutual acquaintance who is also a dancer from Amsterdam. We met up at the end of July in her neighborhood because she had just finished a dance rehearsal nearby.
Harper has a very warm and welcoming personality and was entertaining herself within minutes of beginning the interview. She recalled very much enjoying dance as a child and as a teenager and felt incredibly supported by her parents to pursue dance. Coming from this positive place, Harper notes that she felt like a ‘big fish in a small pond’ towards the end of her secondary education. This led her to move clear across Australia to a well- known performing arts conservatory in Western Australia where she has been accepted into a three year full-time ballet course where she earned an advanced diploma. Moreover while there, she was accepted into her university’s contemporary, graduate student dancer company. While training, she was exposed to many styles some that were “coming from ballet” and others were “moving towards a contemporary practice that often deconstructed the fundamentals of ballet.”
Harper has been out of college for about ten years at the time of our interview.
She recalled that directly after college she was able to travel to many cities throughout
Europe and Russia as one of six dancers in the a company that embarked on a multi-week tour. She described this experience as socially intense as the dancers “live together, work together, sleep together...I don’t think there are that many professions that do that with such intensity; incubator bonding”. After the experience of touring and living in Europe,
Harper relocated back to Western Australia, and was a freelance dancer for six months, until she made the move to Sydney where she has been ever since. Just last year she 127 completed her Master’s in Dance and Creative Practice with “a little bit of
Anthropology”. Her consistent employment at this time is teaching dance, managing a dance space in the city, and continuing to choreograph her own work and be in a variety of other projects.
In terms of healthcare, Harper finds the word ‘healthcare’ to be an American word
- something that is dependent upon employment. When considering aspects of self-care, seeking medical attention, and mental health, Harper leaned on the word ‘maintenance’.
She immediately relates this term to a moment in her training where her “body was just freaking out and nobody could talk to [her] about that” and therefore she felt labeled as “a dancer with a poor memory” or with a learning disability. She feels that self-care, awareness of mental wellbeing, and caring for the mental aspects of training are key parts of “maintenance.”
Concerning mental health, Harper has two distinct experiences from her training years. One was the highly perceived prevalence of eating disorders that her peers suffered from. She noted that while she did not struggle much with eating herself, her battle was with anxiety. In college she notes she was isolated with her anxiety but at the time felt that the harsh emotional conditions she faced in school were preparing her for the difficult status of being a freelance dancer out of school. The anxiety she felt combined with her difficulty with memorization of choreographies inspired her to write her thesis about motor learning in dance. Post college she has found her own ways through trial- and-error to manage her unique learning style and takes on projects that work with her talents rather than against. 128
Her method of management reminded me of other Somatic practices - Harper confirmed that she enjoyed “Feldy” (short for Feldenkrais) but it was expensive to go to the classes as they were out-of-pocket. She also enjoys going to yoga classes, but due to the expense she has instead built up her own collection of yoga tools such as a bolster and a few blankets and often practices Restorative Yoga on her own after rehearsals. Also related, she owns several tools that one would typically classify as staples of physiotherapy that she will use as well (such a tension release balls and elastic resistance bands).
Thinking about seeking help, one of Harper’s teaching locations is a part of a large local company. This proximity gives her access to the in-house physiotherapist.
However Harper did not find this physiotherapist to be a good fit for her as the projects she takes on and her style of dancing conflict with the company’s typical repertoire and therefore the physiotherapist proved less effective in adapting to Harper’s unique needs.
Ultimately, Harper has yet to find a physiotherapist she really loves so she places greater trust with her massage therapist, Pilates instructor, and primary physician. It was apparent that she really enjoyed the cooperative approach of her Pilates instructor and massage therapist because they are a married couple who operate both practices out of their home.
She noted that when she arrives she is offered tea and it is generally a very comfortable experience for her.
These practitioners were well-utilized the year prior to our interview when Harper was the female dancer in a filmed dance duet. It’s important to draw attention to the different stressors that exist on a filmed production as opposed to live: in this instance there were a myriad of individual schedules that had to be coordinated which resulted in 129 extreme pressure to produce within the allotted time. With this in mind, Harper describes the environment of the day in question as “really cold” and as she danced, she “went for it” and ended up twisting her knee in such a way that resulted in immediate swelling, pain, and inability to straighten the joint. In retrospect, she noted that she must have been
“in a bit of shock” because she kept dancing - partly doubting the seriousness of the structures affected and partly because of the pressure of the aforementioned situation produced by the film set. After attempting to let the injury heal with time, self-care, and professional massage, Harper decided to seek medical attention from the companied physiotherapist previously mentioned. This interaction added to Harper’s distaste for this physio noting that the physio seemed to criticize the fact that she had waited two months to seek treatment and didn’t understand Harper’s performance needs (Harper’s impression being that had she been a company dancer, she may have been able to take some time off with such a serious injury negating the need for immediate healing).
Another distressing interaction Harper described about a physiotherapist is from her touring time in Europe when she had a stress reaction around her L5 vertebrae.
Harper felt that the physio gave her some terrible advice when he advised her to (while at home) insert her fingers into her vagina and squeeze - the idea to strengthen her pelvic floor. She noted that this may have been her worst help-seeking experience to date.
Traits that Harper does appreciate in practitioners are listening skills, having faith in their own abilities, belief in the patient to heal and return to dance, and an understanding of her financial and professional needs to return to dance without much break. She also likes when she leaves an appointment with more knowledge about her 130 body then when she began. This is the primary way, she said, that she’s learned about her body, its functioning, and its healing processes.
The two injuries noted prior with a few other non-descript ankle sprains make up the majority of Harper’s injury experiences and those of seeking care or maintenance.
She notes that after her decade of being a freelance dancer and dance educator in the city she feels much more capable of self-care bordering self-treatment. In terms of paying for the mentioned services, Harper does have private health insurance which she says typically only covers seeing the physician and is expensive. She has been paying for private health insurance since she was 26 and was no longer eligible to be on her parent’s private health insurance plan. She continued enrollment with private health insurance without dilemma, as continuity seemed less complicated of an option than change.
Through her stories and our conversation, my conclusion is that Harper is an adaptive and industrious dancer in Sydney and her drive will only lead her to deepen her practice as she continues to perform maintenance for her health and wellbeing.
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Una
New South Wales, August 2017. During the three months that I visited Australia for this project, I decided to rent a different room in a different host’s home each month.
It was providential that the first month of my stay in June 2017 that I was living with a
New Zealander theater producer in central Sydney who was full of suggestions of dancers
I should interview. This led to me Una. Una and I met once over lunch where I explained the project to her and again about a month later to conduct an interview. She provided great insight into not only her own training journey, but to dance students of the current day as her second career has been in education and outreach through two large professional dance companies in Sydney.
Una began dance training at the age of 14 and by 16 she transitioned out of traditional high school and began focused full-time dance training. By 18, she completed her dance Diploma certification at a ballet company in Melbourne and shortly after graduation was employed as a professional dancer in a Dutch contemporary dance theater company. She danced in the Netherlands for seven years, working with a variety of choreographers and toured nationally as well as internationally. After seven years she moved back to Australia and freelanced for one year before she began another three-years of employment with a major Australian dance company. After these three years (her tenth year as a professional dancer) Una made the decision to retire from dancing professionally in order to transition into teaching and start a family. After the birth of her twins and daughter several years later, she continued to teach as well as to take on roles in dance-related committees and funding organizations, and became more involved in the
“infrastructure of the dance sector”. 132
In her forties, Una attended university and earned her Bachelor’s of Art in History and Politics. After university, Una worked for a political research agency until the untimely death of a close friend in honor of whom Una was able to assist her friend’s family and set up a charity which she manages several of the charity programs to this day. She returned to work in the arts and now holds a dual part time role between two major dance companies in Sydney. In one, she is the education coordinator and a freelance consultant; in the other, Una works with the pre-professional dance students in addition to a consulting role.
When I asked Una about her experience of healthcare she expressed that as a person, not as a dancer, she thinks about healthcare in terms of emergency situations
(such as fractures or trauma to the head). When thinking about it as a dancer, Una said
“it’s slightly different because your whole career is an occupational hazard, you can hurt yourself doing it which is why you spend a lot of time training and figuring out how to do things without hurting yourself”. In regard to learning dance technique, Una remarked that during her training as young dancer there was not a focus in learning anatomy and physiology as she has observed in current day dance students. She noted her training was
“get told what to do and just do it, not how it’s being done. I probably knew what a hamstring was, I knew what a knee was, and a foot. But I had very little knowledge of my own anatomy and physiology”. The lack of foundational knowledge about her body and movement led Una to do a lot of figuring out for herself to support her ability to dance with the “nuanced dynamics and sensations” as the choreography in the Netherlands demanded. 133
During Una’s first employment as a professional dancer in Holland, she expressed that all of her health needs were taken care of by the country; not necessarily because of her role as a dancer, but she paid up to 50% tax from her income that went to “medical, transport, everything was very cheap” due to the social democratic political agenda in the
Netherlands at that time. During her residency there, she said she only went to the chiropractor once for a single injury. Since moving back to Australia, Una expressed that she does not need to purchase her own insurance and moreover, she did not mention any further dance injuries during her time as a dance teacher or consultant that required medical attention.
Through her first seven years as a professional dancer in the Netherlands, Una recounted one traumatic injury that occurred on stage. Una told me: “I knew that one of the vertebrae had shifted, I didn't know why it had done it, and I obviously wasn't going to be able to fix it myself”. Not feeling like this was a case for the one esteemed London dance physician at the time, Una opted to seek out a chiropractor in The Hague for the first time the day after the performance. She recounted that the rehabilitation advice she received was “just don’t [dance] and see if it gets better; then just start coming back”.
Since this recovery period, Una feels that “now that it’s happened enough, if I were to feel that same sort of thing, I would know immediately that I need to get on the floor and get my legs in a certain angle and put heat on it; I would know what to do”. Since this process, she noted that she has sustained only a few minor ankle sprains over the course of her dance career. She expressed that her facility, her body, has been well suited for dance from a young age and relates this fact to her rare dance injuries. 134
In Australia, Una is happy to have found a physician/osteopath, that she has had a relationship with for 35 years. She found him when she was dealing with a non-dance related injury in her 20s; the first physician she sought care from “was ready with knife in hand”. She was referred by a friend-of-a-friend to the physician/osteopath. Una gave several examples of how quickly and holistically this practitioner has healed her pain and malalignments. Una noted that she hasn’t needed to see anyone else for her care because he is her main support; Una noted that he treats in a holistic manner which she finds to be
“very important”. Moreover, she noted that he is extremely fit as a 70-year old man as
“the living breathing example” of health for Una - another quality she appreciates.
As mentioned prior, when Una transitioned from professional dancing to teaching dance she was wanting to start a family. At the time Una was making this decision, maternity leave for professional dancers was not a popular concept and was not offered at her place of employment. After becoming pregnant “unexpectedly quickly” with twins, she eventually stopped teaching dance because in her words, “people watching me were a bit disturbed” and the young dancers were asking if her babies would be dizzy. By contrast, during her second pregnancy Una danced up until two weeks of her daughter’s delivery. After telling her story, she expressed to me that currently, the two companies she works for offer maternity leave and moreover, specifically encourages dancers who are mothers to come back with a stronger body and new level of artistry.
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Gwen
Queensland, August 2017. Gwen has been dancing since she was three and says this training became more ‘serious’ when she was 13 or 14 years old. She trained as part of the junior extension program from a local professional ballet dance company. At the age of sixteen she left home to continue her training in Germany. As she completed her dance training in Germany, she had the opportunity to tour as well as perform with an
American ballet company for a nine month period of time. Her training is primarily ballet with contemporary training as well. She began in a ballet company and after dancing for a full year, transferred to teaching after sustaining an injury. Her current role includes helping with rehearsals and auditioning children for the company performances; she’s been teaching for 2.5 years.
At twelve years old, Gwen was diagnosed with an eating disorder which she harbored for several years. At this age, she experienced what she deems her most negative healthcare experience. In this situation, Gwen felt that the initial physician her parents sought care from (a referral from her GP) was overly blunt and wanted her to stand on a scale right away. After leaving this appointment, she found a network of more gentle practitioners (a psychologist, a nutritionist, and a physician) through a family contact. She notes that these individuals were more personable and helped her identify her own positive qualities which aided in her recovery.
During her years of professional ballet dancing, Gwen developed bilateral jumper’s knee and several bone spurs which required surgical intervention. The pain began during her time in the United States, but after dancing in pain for a year in Queensland, she sought a few varied medical opinions (her dance network, a physio, and a knee orthopedic 136 specialists over the course of three months; ultimately deciding to have surgery for both knees simultaneously. The physiotherapist was employed within Gwen’s dance company, so they were able to communicate with the artistic directors on Gwen’s behalf about her limitations and need for intervention. Gwen spoke to me about the decision to take action and being a professional dancer: “being a dancer and being injured, it’s not what you want, so you just keep going through any pain and you try to not make a big deal about anything. But once you find that it is something that needs action, then it’s easier to talk with people about it”. As a young dancer at the time, Gwen noted that she would continue to work through pain because she wanted more roles and more experiences and moreover, didn’t want to be seen as complaining.
Throughout the recovery process, Gwen transferred to the educational department. Even with a full recovery and the ability to continue dancing after six months, Gwen stated that she was enjoying being a dance teacher at that time, and she chose to remain a teacher rather than rejoin the company. She attributes some of her strength and ability to move career direction from her deeply supportive family.
Due to her age at the time of her knee surgeries she was eligible to be covered by her parent’s private health insurance policy. This allowed her greater flexibility when seeking physicians and access to both public and private hospitals. During our interview,
Gwen was still a few years shy of dis-qualifying for her parents’ coverage and told me she has not yet thought about whether she will continue on private health insurance or rely on the public Medicare.
Because of her time spent dancing abroad, Gwen was able to comment on healthcare in the United States, Germany, and Australia. She expressed that the company in Germany 137 had the most governmental support (funding): “they were quite a big company and
Germany funds them really well. So the approach that they can take is [the ability] to afford more services or send more people out to get X-rays”. Compared to her homeland and current country, Gwen stated the funding is not as good but she has seen improvement over time as the companies seek private donors: “their funding is increasing in that they are prioritizing healthcare as well”. Finally, remembering her time in the
United States, Gwen did not need to seek healthcare services, but she did say that the
American ballet company “was probably the least [supportive], I am aware of healthcare, but in saying that I didn't actually have to seek out healthcare there, but from what I saw within the company and what was provided on-site, it was the least”. Gwen continues to teach ballet in Brisbane, Queensland.
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Liam
Queensland, August 2017. I sat with Liam in a glass office in an academic building during August in Brisbane; I had flown there to interview Liam and Gwen individually. I had found them through different means; Liam responded to my initial call-for-participants (in Australia) via email in June 2017 and Gwen was found through a personal contact. As I interviewed Liam, his positivity shone through his stories and left me thinking about sunny dispositions in relation to professional goals.
With 20 years of ballet under his belt, Liam has trained and worked in Sydney,
Melbourne, and Brisbane. He began dancing at the age of four and stayed with a single dance school until he was 16. He noted that during his development and training, his artistically-focused parents were supportive both emotionally and financially. At the age of 9 he began entering dance competitions and recalled a “little spark of excitement” in himself which pushed him to seek more training when he was 16 at a national ballet school in Victoria. After three years of training, he auditioned for his current employer in
Queensland and has been dancing for the past five years in this company, making his way up the ranks.
Liam detailed a typical day for me. Starting at 8:30am, he bicycles into the studio and begins warming his body for a 10am class. Classes will run from 10am until 6pm each day after which he takes some time to cool down and make plans and goals for the following day. A typical day during performance season is similar, though the schedule is moved to later because the performance will go into the evening. Mentally, Liam noted that he is consistently keeping his mind in a future-orientated state; having spoken to me about his future-mindset preparation routine: “making sure that it is not just the day that 139 you are preparing, but the next day and even the day after so we are constantly working from one to two hours ahead to 72 hours ahead”. He further noted that during his days of rehearsal, he feels no mental break from his work and instead remains in a state of focus.
“There is so much that goes into it, about 90% is underwater and 10% is what you see on stage”.
When I asked Liam about how he has developed his skills in mental and physical preparation, he cited the long-term injury of a past back stress fracture as a major learning opportunity. It was at this point that it became clear that Liam is a firm believer in finding the silver lining, the “yin and yang” as he put it, to any situation. When thinking about healthcare, Liam responded with the words “reassurance” and safety”. He emphasized the importance of trusting that healthcare support is available so that he as the artist can push his boundaries and achieve the results that the artistic director is aiming for. He noted that this trust has come with experience and age; Liam noted that at a young age he was preoccupied about sustaining an injury and the negative impact it would have on his future career. An additional stressor being that at that time and throughout his training, the responsibility of paying for physiotherapy was on Liam and his family. It wasn’t until his current full-time position in the company that physiotherapy became covered by his employer. Because medical care wasn’t included for over 15 years of his dancing career, he built up a resilience as a dancer, and was forced to learn how to self-manage smaller injuries.
Moreover, as a teenager, Liam expressed that he had depression and would call home to his parents in tears after dancing. His parents encouraged him to seek out mental health counseling which led him to form a relationship with a psychologist. He noted that 140 in addition to gaining the biomechanical and anatomical knowledge from physiotherapists, he also gained strategies and a philosophy from his counseling sessions which combined have attributed to his resilience and sunny disposition. He concluded by saying that seeing his psychologist was instrumental in his ability to work with and through his depression.
Around the same time, as a teenager, Liam participated in many dance competitions in Australia. At the age of fourteen, Liam sustained a back injury which he attributes to an improper lifting technique of his female partner. He said that after the initial injury he was feeling pain but decided to compete in an upcoming competition, taking ibuprofen to “cancel out the pain”. After his performance, he sat with his parents in the audience and 45 minutes later realized he was unable to stand up. After a failed attempt at over the counter remedies, Liam was ordered an MRI that confirmed three stress fractures of his lumbar spine vertebrae. Before this event, Liam’s only experience with bone injury was a quick healing humerus fracture when he was 8 years old. The physician involved in the care of Liam’s back advised six to eight weeks of no dance, however Liam, on reflection, notes that at the time he was not mature enough to consider the seriousness of the pathology and felt “invincible”. After four weeks of rest and wanting to compete he returned to dancing which ended in a re-fracture of the segments.
By this time, Liam had turned sixteen and was more privy to the high expense of seeing lumbar vertebrae specialists. He noted that a re-injury episode happened “two, three, four” times before he finally took a step back from his desire to compete and really slowed down. He made an interesting observation in terms of communication with medical professionals saying that what was said to him was “six to eight weeks of 141 healing” but he heard “six to eight weeks until [returning to] dancing” which was negligent of the rehabilitation process. He notes that the third time around with recovery he actually came back stronger than his pre-injury self because he had more understanding of his body, the anatomy involved, and the healing process. Liam notes that when he had a 30-minute physiotherapy session, he wanted 30 minutes of information to take away and learn from as well. He called this injury “the steepest learning curve” he has experienced.
The network that Liam had created at the time of the interview included a general physician and a physiotherapist local to him, in addition to an osteopath and Pilates instructor when he visits family in Sydney. Liam told me about his Pilates instructor, (a former dancer) and how he demonstrates an interest in the body and current research.
Liam attributes much of his own body knowledge from the teachings of this practitioner.
Liam noted that “it's great to be able to talk to an ex-dancer about your body because they know where you come from and what you've been through”. Re-thinking the professional dancer and healthcare, Liam turns to the example that professional football sets in
Australia. Liam is an advocate for more science to be interjected into dance medicine, not only to support the dancer’s knowledge of their own bodies but to place dance and sport on a similar level. He sees professional athletes as equivalent to professional athletes and would like the healthcare support systems to reflect that.
Recognizing that he may be a third through his professional career (a professional male ballet dancer typically retires at 35), Liam aspires to dance on as many international stages as possible and keeping that spark of excitement alive.
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Emerson
Victoria, August 2017. Emerson’s immigration status in Australia made him a unique interviewee. Emerson is a European-born dancer who is currently dancing for a major Australian dance company. I spoke with Emerson during his rehearsal season, at a public library in August of 2017. Since completing his training, Emerson has danced with one company professionally. He is currently on a 12-month contract with this company and typically performs eight shows per week when in a performance period. Over the course of a year, the ballet company will have between 180 - 200 performances.
His dance training began alongside a female friend when he was 6 years old and was finalized in France and England. During the French portion of his education,
Emerson would spend mornings practicing ballet and afternoons and evenings in traditional high-school classes. This training lasted for two years until he completed his high-school education in this format. Emerson then moved to England as a teenager wanting a more immersive program. In England, Emerson’s school was affiliated with a major performance company and he was afforded the opportunity to become a full-time dance student. His final year enabled him to audition globally and it was through these auditions that he was recruited by his current company.
Emerson is a unique subject because as an immigrant he is not eligible for the public health system that his Australian peers qualify for inherently. Because of this,
Emerson purchases private health insurance which is further supported by the on-site medical services his dance company provides (ballet coach, physiotherapist, Pilates instructor etc.). Emerson speaks highly of these services particularly the ballet coach who demonstrates communication with the other professionals within the provided medical 143 team. He finds that the ballet coach is particularly helpful in collaborating to form an individualized rehabilitation and performance training program for Emerson to work with.
Emerson communicated that each dancer’s technique is so individualized that sometimes having a ballet coach’s input can be jarring, but he appreciates honesty and the keen eye that the coach can offer. Emerson further explained that the ballet coach was able to augment his own ability to identify the compensatory movement patterns that his body (facility) falls into. The overarching purpose of the ballet coach is to help Emerson and his colleagues with performance enhancement and injury prevention.
Emerson has had two primary injuries over his career. The first being a 5th metatarsal fracture (also known as dancer's fracture) when he was training in London and the other a manifestation of medial tibial stress syndrome more recently in Australia. The experiences he had in the diagnosis, treatment, and rehabilitation of each injury were vastly different. When he sustained the fracture he was a full-time dance student, and while his school did have an in-house physiotherapist they prioritized company members and thus Emerson had limited access. He did see the school physiotherapist initially, but primarily rehabilitated the injury himself. This self re-conditioning saw the development of some anterior ankle impingement and led to a period of time in Australia in which
Emerson danced in pain. This ailment has since been identified and worked through by the medical team at his current company.
The second injury, the manifestation of the medial tibial stress syndrome,
Emerson traces to the three-week holiday period he had for summer/Christmas. This pain was occurring at the time of our interview and did not have a resolution. However, 144 contrary to the previous pathology, Emerson noted that he feels much more “looked after” and knowledgeable about his current injury status. He continues to work with the ballet coach through the healing process.
After relaying the details of his physical injuries, Emerson told me about the emotional pain that goes along with injury and how he expressed that pain to the physiotherapist. Moreover, Emerson has taken advantage of the in-house sport psychologist in the past and expresses appreciation for the service. He compared finding a well-matched psychologist akin to finding a soulmate; a very temperamental process.
However, on the flip side he notes that finding the best-fit psychologist may not be possible given the time-constraints of his full-time dancer status. Therefore, when
Emerson sought out counsel from the on-site psychologist, he felt that he was able to
“make it work”.
Emerson has many positive things to say about Australia. He commented how everyone in his current city seems to be fit and take care of their health, this in contrast to an impression he carries of Londoners being less well. Emerson is currently pursuing a
Bachelor of Arts in dance alongside his professional status with the company. He feels that studying is positively impacting his wellbeing and making him a more introspective and grounded artist. He also actively engages with media from his home country, as he is the only person from his country in the company, hearing his native language on the radio and reading those newspaper is an important part of his wellbeing. On a final note,
Emerson was perhaps the only dancer who didn’t feel like he would use the word
‘passion’ to describe his connection to dance, saying that “passion is a heartbeat and
[dance] is so much more”. 145
Yasmin
New South Wales, August 2017. Yasmin is an Australian dancer whom I met while in graduate school in London. A more personal connection, she is a former classmate’s partner and it was this classmate who recommended to Yasmin to be interviewed and participate in my project. The three of us met at the New South Wales
State Library in mid-August and Yasmin and I found our way to the reserved, glassed-off meeting room to conduct the interview.
Yasmin started dance in pre-school in a small town, in an equally small dance school, performing jazz classes. When she was seven, the school closed and Yasmin’s mother found a “proper” dance school where she continued to train, foregoing other extracurricular activities until the age of 18. Here she danced six days a week with competitions on the weekends year round. Yasmin expressed that since she was a child, she has loved the feeling of movement, “it just feels good”; it was this love that kept her interested in the pursuit of dance. Meanwhile, Yasmin was completing her academic studies through her year 10 when she opted to leave school and to do a year of full time classical ballet training which capstoned in a European tour for auditioning purposes.
Also notably, during Yasmin’s childhood she routinely shadowed her mother during visits to the chiropractor and also received “mini-adjustments”; this repeated action shaped her relationship to pain and healthcare throughout her training.
During her time training at this ballet academy, Yasmin stated that this is when she learned that her facility and physicality was not suited for classical ballet. She learned this after being held back in some of her ballet classes and remembered being devastated at the time. She recalled that her teacher had some unhealthy advice for her saying: “it's 146 your weight, you are too heavy set”...but she didn't sort of shoot it down and say it's not possible, her method of coping was just don't eat as much...a bit unhealthy really”. In one instance, Yasmin recalled a time when her teacher accused her of eating sugary snacks and instructed her to eat chocolate cake protein/diet bars as substitute whereas for
Yasmin, her diet didn’t consist of sugary snacks but more of a balanced diet of fruits, vegetables, and proteins. Knowing that her diet was healthy and that restriction was not an option for her, she acknowledged that some of her peers were restricting their diets and a few naturally had the body for classical ballet; moreover, in the interview Yasmin added that two of her classmates are presently managing eating disorders - hinting that she had been at a risk for developing that way as well.
After confronting this particular teacher’s assessment of her, Yasmin rediscovered her enjoyment of the more contemporary styles that had been stifled throughout the year of ballet training. She decided to transfer to another full-time dance academy that focused on a more contemporary ballet style and jazz; Yasmin noted that even though the issues around the shape of her body were less at the new school, they were still an issue. When she finished the program, she earned a certificate and created a dancer film reel which she sent to several graduate schools around Australia and international dance schools.
She was able to earn her Bachelor of honors in Dance Appreciation. Comparing her contemporary training in Scotland to her past training in Australia, Yasmin said:
there [were] no lectures that were telling me “you need to lose weight, you don't
have the right physique”, instead, they just wanted me to be fit and healthy, [and]
were more focused on getting your stamina up so that you could keep up with 147
different dance routines. Individuality was accepted a lot more, the focus wasn't
on what you looked like, it was more about how you moved.
In the United Kingdom, Yasmin auditioned for several companies and was again accepted by two, choosing the one located in London. She spent the following year dancing and touring with that small contemporary company, while also earning her
Master’s of Arts degree in Dance Performance. Throughout graduate school, she found that she preferred being in the rehearsal space rather than the stage saying:
I much preferred the rehearsal process and I'd get quite nervous going on stage. I
just didn't enjoy being on stage, whereas talking to other dancers, they all thought
it was quite weird, [because] everyone else was the opposite, they thought the
rehearsal process was a bore for them, but being up on stage made it worthwhile.
She went on to say that these conflicting feelings with her peers reinforced that she didn’t want to audition for anything so when she moved back to Australia after her visa expired, she began teaching contemporary dance and ballet. For the past three years, she has been teaching and expressed that she loves it.
Before starting her studies in Scotland, Yasmin took six months off away from dance. During this time she began suffering from a sore back, disproportionate to the minimal amount of work she was doing; and sought advice from her childhood chiropractor. Learning that her back had become deconditioned, she also learned that she had developed scoliosis within only a couple of months. Throughout her time in Scotland and London she continued seeing a chiropractor preventatively “to keep [her] back pain at bay, even though [she] wasn’t experiencing any back pain”. Upon her return to
Sydney, she began questioning this practice and hasn’t been to a chiropractor since. 148
Yasmin has also experienced minor shin splints during her year of classical ballet training. She sought care from a physiotherapist at the time and continued seeing her for about a year. While in graduate school, she developed a left ankle injury. She saw the in- house physiotherapist and said that his proposed treatment would be to undergo a surgery; however, it was at this time she was questioning her own desire to perform after graduation and ultimately decided not to have the surgery and today manages the ankle through reduced range of motion.
Thinking of the practitioners Yasmin has interacted with, the chiropractor that she visited whilst in graduate school stood out. She transitioned to a new chiropractor that was closer to her house and she expressed some skepticism early on: “at first I was just lying on my stomach and it sounded like he was clicking his fingers over my spine and clapping by my ear and I was just like, ‘this guy is nuts’.” She stated that the method he used was called the McTimoney Method and she grew to appreciate it because “it made
[her] feel amazing with less force”. Yasmin expressed that not only were the results good, but the practitioner was knowledgeable about the effects of treatment, warning her of nausea before feeling relief after treatment. When I inquired if she ever saw a different kind of practitioner for her back pain, she replied “no” and moreover: “maybe it's from my Mom, her way of thinking about it [...] I've only recently been introduced to the fact that chiropractors can work on other parts of your body and likewise [that] physios can also help with back problems, [...] it's not like it's cut down the middle”.
When asked about her knowledge of the health insurance system in Australia,
Yasmin responded that she gets her information from her mother, adverts, and the internet - joking that she can’t verify what her mother has told her. Yasmin was 27, 149 meaning that she had been removed from her mothers’ private health insurance policy two years prior at the age of 25 - a common age for young adult Australians to seek purchasing independent policies. Since then she had not purchased her own private health cover, but was weighing the pros and cons. She finds the pros of private health cover to be “probably a bit more choice and a little bit more certainty”, specifically the ability to jump ahead in waiting lists and being able to choose the physician. Since being on the public system for two years, Yasmin has needed an emergency appendix removal and had a positive review of her experience:
In the emergency ward, I was a little bit scared [because] my mum's always had
private health insurance so I didn't know what to expect. It was actually amazing,
I got in there [and was] in a ward with all these other people, but I could pull the
curtains so that it was private and the treatment, the staff, and the operation was
amazing. That was a really positive experience.
She further remarked that she feels equally satisfied with the care she’s received from private hospitals and public hospitals.
For Yasmin, self-care involves doing physical activity on top of her dance instruction every day for about 30 minutes, meditation three times a day for a few minutes, and sometimes taking a yoga class. She explained that she developed her routine in conjunction with a psychologist. After a boating accident when Yasmin was nine, she began speaking with a psychologist and has seen one (not always the same one) on and off since then. She currently speaks with a psychologist who is her best friend’s mother and explained “I feel like I need to just check in and get some more tools on how to manage anxiety or mood swings”. Yasmin noted that she did not seek counseling 150 throughout her dance transitions (from ballet to contemporary or from performing to teaching), when I had remarked on that she reflected back to me that her peers have noted her resilience, even if she has questioned it herself - “I think in some aspects I am, like with dance I am, but then I feel with other aspects I am not resilient at all”.
Currently Yasmin is teaching part-time in four different schools in and around
Sydney. I asked Yasmin what kinds of messages she hopes her students are receiving from her classes and she responded:
I really try to make the focus of the classes enjoyment and improving and that it is
okay for the end goal not to be a professional ballet dancer or a professional
contemporary dancer, but you are having fun and learning something and seeing
where it takes you. Just come and learn something, grow, enjoy yourself, I hope
that's what they take away.
151
Kat
New South Wales, August 2017. Kat and I met at Sydney University's library where I was spending my summer of 2017 doing this project. She had just arrived from teaching a Pilates class and was dressed athletically. Kat approached me about being interviewed after seeing an advert I had posted on a social media page that targeted independent dancers in the Sydney region. Kat was the penultimate interview conducted for this research (the last in-person interview as well), and her story provided insight to a first-hand account of a problem with the public health system in Australia.
Kat began dancing when she was five years old. She decided to become much more serious when she was eight transitioning into a 20 hours a week dancing schedule.
When asked what inspired this decision to specialize at this age, she responded with words such as “love”, “cool”, “exactly what I wanted”, “passionate”, and “determined”.
This drive led Kat to a hybrid high school situation (half days of high school combined with half days dancing). To further her training, she moved from New South Wales to
Western Australia to enroll in one of the largest performing arts programs in Australia.
Here, her schedule intensified to six days a week and about 60 hours of dancing a week.
After two years, she earned a certificate in ballet dance and it was at this time she felt that her physique was not best suited to continue in ballet. For this reason, she transitioned into a contemporary honours program. Kat describes this experience as ‘hardcore;’ noting the competition, small class sizes, and being pushed to her potential by faculty. In reflection, Kat feels she was lucky to be accepted into the program and that it was ‘an amazing experience’. She told me that sometimes things like self-esteem, confidence, and mental health can be sacrificed when aiming for intense physical training; moreover, that 152
“anxiety and depression and eating disorders and that sort of thing,[...] was all sort of going around”. In an ideal situation, she spoke of the school purchasing access to a dietician, a performance psychologist, massage therapist, and a physiotherapist to care for its students. Finally, she notes that in the situation she was in, that communicating between dance teachers and not-on-site medical professionals was an extra step and not the most efficient model she observed when comparing her program to other elite ballet training programs.
After this, she spent three years in Western Australia freelancing as a contemporary dancer. She notes this work lifestyle was either off, or heaps of work.
Currently, and for the past two years, she has returned to New South Wales (specifically
Sydney) and now has two career paths. One is teaching Pilates which she became certified in doing about 18 months prior to our meeting. The other being a dance teacher for persons with physical disabilities. She says she enjoys transferring the passion for the art form.
In terms of healthcare, Kat is currently dealing with a medical issue, so much of her story was quite fresh. Recently, Kat dealt with a general medical diagnosis involving her GI system. Her chief complaint was that her gut went from “a slim dancers belly” to looking “four months pregnant” (her words). After a poor experience with one GP who conducted a simple blood test, which was negative, diagnosed her with an unknown food allergy and gave her a card, not a proper referral, to a local dietician. In the early stages of looking for a diagnosis, Kat tried an elimination diet to try and identify a food allergy.
This was unsuccessful. Still looking for answers, Kat sought care from another GP she already knew and had a much more successful, comprehensive diagnostic experience. 153
The most current diagnosis theory to her ailment stems from a long-term use of anti- inflammatory medications (taken for years for pain maintenance of dancing with a metatarsal fracture). The theory suggests that the consistent dose of anti-inflammatory medication wiped out her gut bacteria and from this the ‘bad’ bacteria began to overgrow and cause severe bloating and pain.
To reach this diagnosis was not without cost. As a student, Kat has private health coverage from her parents and a lack of income from her student status. During the time of this GI ailment, Kat was off her parents health coverage and was given two options.
Seeing her public GP, the follow-up specialists that led to her unique diagnosis, antibiotics, and a GI medical procedure ended up costing 3000 dollars out-of-pocket. Kat could have had to wait an additional “two to three” months for those appointments on the public system, but decided that she could not wait this long for a diagnosis. Furthermore, as a full-time dance/Pilates instructor, she ended up being able to afford the procedures on her own up front.
Tracing the cause back to its source, Kat attributes her use of anti-inflammatory medications to her days in training when she was dancing through pain and injury. In reflection she realizes it’s not best practice to “eat heaps of Voltaren so you can't feel your foot and then keep [dancing]”. Kat noted she was instructed to take anti- inflammatory medications from physicians and physiotherapists who were well aware that pain will not stop a dancer from dancing. Effectively masking the pain, but not addressing the cause. She critiqued the system as it was, (perhaps still is) saying that there was not a nutritionist to advise her more about the medications effects on her 154 stomach or to eat food with the medication. She remembered “I'd just take them with no food, I had no understanding of what it was doing to my insides”.
Thinking about a holistic version of health, Kat circles back to the lack of clinician support during her time training, specifically in nutrition and mental health matters. Kat acknowledged her perception of a high prevalence of eating disorders within her own dance program. She feels like her own research and experiences have since increased her understanding of the benefits that a dietician and counselor could have on a dancer and on their performance.
Kat spoke about bulk billing for a bit - that her “good GP” had a 100 initial cost to see her and booked about 2 weeks out. The more negative experience she had was free (paid for by the government) but she felt that the doctor rushed her in and out of the door with a prescription in hand. Thinking about this, Kat notes that she appreciates that everyone in
Australia has access to healthcare services, but when she has the ability to wait and spend money, she feels she is getting a better quality for certain services. She says that using the quicker-scheduling general practitioner for a ‘pill repeat’ versus a private pay general practitioner (who typically schedule farther out) who are better suited for more complex diagnoses. Kat’s story made me much more aware of dancers’ habits and struggles when using of anti-inflammatory medicines and I wished her the best in a full recovery.
155
Ida
Sydney / Northern Territory, August 2017. Ida was the last dancer I interviewed for this research project and because of her location (Darwin, Australia) our interview was conducted via video. Ida began her ballet training between the ages of six and ten while also dancing jazz and socially (non-technical) in primary school. It was at the age of fourteen that she met an Indigenous choreographer and began training with him; this was her first experience with contemporary dance. This enjoyment of dance led Ida to earn her bachelor's degree in dance from an arts college in Victoria from which she graduated about six years prior to our interview. Her degree was completed in two segments as she took a year off in the middle to address mental health issues of depression and complicated relationship with food.
After graduating from university she was a freelance dancer for about three years until becoming employed by a community-based dance company with whom she is still working. Her responsibilities within the company include running workshops, teaching, directing rehearsals, warming cast members up, giving notes, and choreography.
Currently, Ida is also beginning the process of becoming a certified Lyengar yoga practitioner which entails five years of practice, 300 hours of training and an additional
100 hours of assisting. In conjunction with yoga, Ida also practices Pilates; these two practices, especially yoga, offer her a mindfulness which she finds enriches the movement process in her body, and she enjoys the physicality and awareness that she gains from them.
Ida’s knowledge about the human body began during her bachelor’s; she describes the process as very experiential-based, performing movements supplemented 156 with a description of the working anatomy. She recalled “my ballet teacher just had an incredible kind of understanding of [the biomechanical] side of it and brought that into the classroom without it being a lecture”. Her first year anatomy teacher was also a physiotherapist, so her education covered common dance injuries, diet, and nutrition. Ida noted that the lessons were not too in-depth, but it was practical and applied learning as her teacher was the school’s in-house physiotherapist. An aspect that she noted was missing from this education was addressing the psychological side of eating and diet for dancers and athletes. This is a topic she felt herself and her peers were struggling with and formal guidance and education were missing.
Upon further reflection of her first year at university, Ida painted a picture of an environment that offered much support for technique and dance, but little in the way of support for the dancer as a person. Even with a small-class size (under 30) and consistent teacher interaction, Ida experienced a lack of attention to her wellbeing. She felt as if she was pushing herself physically while managing a general status of homesickness (being a plane-ride away from home). At the end of her first year she experienced a lateral ankle sprain that healed incompletely and transitioned into a tendinitis in her ankle. Ida perceived a lack of communication about her holistic health between the school physiotherapist and her school’s core teaching faculty that allowed her to push herself to a point where the healing process suffered. This year cumulated into an end-of-year review, which resulted in Ida breaking down in front of her assessors and the decision to take a year off to see a psychologist for depression. After this year away from her studies, she did return to university to finish her degree. 157
Since university, Ida mentioned only one significant dance-injury: patellar bursitis. This happened from a fall on one dance project (contract A) but it didn’t inflame and become symptomatic until the following project (contract B). Unknown to Ida until it was needed, the dance project with contract B had Worker’s Compensation allowing her to seek treatment quickly and effectively with a dance-knowledgeable physiotherapist and a sports medicine doctor. This injury was during Ida’s only gap year between leaving her parents private health coverage and purchasing her own which she has maintained ever since (and says is not as good as her parent’s coverage). Even with a gap, being an
Australian in Australia means she was still covered under Medicare. She mentioned that after resolving her bursitis, she looked through her contracts more closely for workers compensation, noting that before she would skim past those details in a contact.
Moreover, she noted that having a dance project to be a part of was still more important to her than guaranteeing insurance coverage.
Knowing Ida had her own private health coverage, I asked her about any barriers to care, to which her answer was very unique to this interview. All of my other interviewees were dancers working in cities, so it should be of no surprise that Ida’s barrier to care was being far away from medical services. She gave an example of a time when she had a facet issue, but the only available medical professional was a nurse who dealt more with general medical conditions more common to remote Indigenous communities. Ida worked through the pain for three weeks before seeing a physiotherapist with a dance-background. Ida continues to work for the community dance company in which she is able to work with fellow dancers, school-children, and within
Indigenous community contexts amongst others. 158
Chapter Five: Results
Introduction
Dancers have been the subject of research for decades as an emergent population; and while dance medicine and science is not new, interviewing dancers to comment on topics related to the field is novel. There is limited previous qualitative research on dancers wellness; some literature exists examining the wellbeing of dancers, experiences with retirement, career transition, as well as performance anxiety (Roncaglia, 2008;
Walker, Nordin-Bates, & Redding, 2010). Disappointment, appreciation, discovery, and adversity related to accessing healthcare and interactions with healthcare practitioners were explored as these concepts arose in the interviews.
During the American interviews, political events were happening - a presidential campaign season where healthcare was a major debate topic (Vivian), the election of a new president (Nora), and the inauguration and initial months of the new administration
(all other American interviews). Contextually, it’s important to be mindful of the fact that these events were occurring and were prominent news in the United States at the time.
This chapter discusses the themes and patterns that emerged from interviews of twenty dancers specifically regarding how they’ve cared for and sought care for their health and wellbeing. This chapter is complementary to the participant narratives presented in chapter four; because some data applied to numerous themes that data are presented more than once. The data from the interviews have been transcribed, coded, and analyzed according to the primary four research questions proposed at the start of the project: 159
● How do dancers in the United States experience their healthcare including access
and satisfaction?
● How do dancers in Australia experience their healthcare including access and
satisfaction?
● What aspects are unique or similar between American and Australian dancers’
experiences and perceptions of healthcare?
● What are the experiences with healthcare for dancers who have lived through a
transition (pregnancy and injury)?
Chapter five is organized to first address the two research questions (combined): how do
American dancers and Australian dancers experience their healthcare including access and satisfaction? Some small themes were unique to the American dancers while others were unique to the Australian dancers. For the most part, an effort was made to compare similar aspects of the healthcare experience in both groups.
The third research question, what aspects are unique or similar between American and Australian dancers’ experiences and perceptions of healthcare?, is then addressed under the headings Unique Qualities and Similarities. The fourth research question was narrowed to address only pregnancy specifically, because as data was analyzed, the process of injury was prevalent throughout many other themes; the data discussing pregnancy is under the heading Dancers and Pregnancy.
Results of Pre-Interview Survey
Dancers were given a survey with 14 questions; to see specific questions, readers should go to Appendix B. Seven dancers (4 American; 3 Australian) selected all conditions for self-identifying as a dancer. “Have a record of performance” and 160
“Consider myself a dancer” were chosen by all dancers (N = 20); all other conditions were not consistently chosen. Half of all dancers (5 American and 5 Australian) noted they made most of their income from dance. One dancer was fully retired from all employment, all other dancers were working either as dancers or in a related field such as teaching and administration. The frequency of choices is displayed in Figure 3.
The average percentage of yearly income spent on out-of-pocket healthcare costs was 4% of the fifteen dancers who answered; Americans (N=6; 6%) and Australians
(N=9; 3%). Four dancers had experienced pregnancy while dancing, all dancers had experienced an injury while dancing, and all except one dancer did not stop dancing when referencing their latest injury.
The type of medical professional that was sought out after injury varied with the
American dancers (Medical Doctor=5; Alternative practitioner=3; Physical Therapist=2) while all Australian dancers sought care from a physiotherapist (N=10). The time to seek care ranged from immediate (0 days) to 8 weeks for the American dancers with a mode of
0 days. The time to seek care ranged from 1 day to 4 months for the Australian dancers with a mode of 1 day. The difference between time to wait for an appointment was 3 to
60 days for American dancers and 1 to 14 days for Australian dancers.
The final section of the survey asked about the most important aspects of treatment for their dance related injury. Three options were predetermined (elimination of pain, good relationship with provider, and the ability to return to a pre-injury level of dancing) with a fourth option that was fill-in-the-blank. Two American dancers opted to write in that having their overall health managed and receiving a proper diagnosis were the most important aspects of treatment with speed of recovery, and low-cost also 161 presented as write-in answers. Finding a proper diagnosis, or a diagnosis that was the root of the problem, was written-in by three Americans total. For all 10 American dancers, having a good relationship with provider was ranked at least important with elimination of pain and ability to return to a pre-injury level of dancing tying between first and second choices. Three Australian dancers wrote in the following options: the ability to keep dancing through rehabilitation, the opportunity to learn about the self through rehabilitation, and having emotional support. All three weighted those as the second most important aspect of treatment. While elimination of pain tended to be the most important aspect, relationships with practitioners tended to be ranked least important, although not exclusively for either. Roughly assessing all the dancers’ answers, it is clear that eliminating pain and returning to a pre-injury level of dance is more important to the dancers than a relationship with their healthcare provider.
Americans and Health Insurance
My impression of the national pulse in America during the months of interviews
(August 2016 through May 2016) was that of general anxiety and uncertainty towards what was going to happen with the new administration in place, particularly with healthcare policies such as the Patient Protection and Affordable Care Act. Having health insurance acts as a financial safety net for Americans, even with a high deductible, in the case of major surgeries or fluke accidents; health insurance protects consumers from unmanageable healthcare debt. American dancers were insured in four ways; five dancers purchased health insurance through a government sponsored (Subsidized/Medicare) marketplace (Vivian, Jade, Zoe, Olivia, and Nora), two dancers’ health insurance was sponsored by their employer (Sam and Benjamin), two dancers were insured under their 162 parents’ health insurance plans (Coral and Fern) and one American dancer, Quinn, purchased joint health insurance with her husband. Insurance took the form of discussions around commercial health insurance such as Blue Cross / Blue Shield,
Workers Compensation, accessing care through community clinics, or a sliding scale fee system.
Having or not having health insurance brought up a range of emotions and reasoning. Zoe noted it was particularly important for her to have health insurance because as a parent, protecting her own health and her children’s well-being was of the utmost importance. Vivian expressed that she does not trust insurance people “at all”.
Fern who had found herself injured at work told me that she was feeling too awkward to call her past employer to get compensation for the rehabilitation costs. There are certainly many more emotions that came through in the American dancers interviews which are discussed in the following three emergent themes: 1. Mindfulness of resource, and 2. The
Patient Protection and Affordable Care Act.
Mindfulness of resource. Dancers voiced varying levels of appraisal of the value of having or not having health insurance. On one end of the spectrum, in a short sentiment Nora said “It means everything, it means safety, it means comfort”. Quinn, told a story about learning the importance of having health insurance from a time she sustained an injured during an audition. After getting the role, Quinn had felt as though she got away with something when the company that hired her covered the expense of her rehabilitation. She went on to comment “it was my first awakening to being an adult and Oh that’s why you need a doctor, that’s why you need insurance because there may 163 be times when I am between contracts and get hurt”. Olivia commented on how being aware of healthcare costs affected her dancing:
You can’t afford to pay for another surgery of overuse and kind of battering
yourself so I think it’s not so much as giving up dancing which I think would just
kill me, but it is also being more intelligent about how much and how hard, you
know it’s approaching things from a more intellectual standpoint, than a brute
physical, I am going to do it.
Life experiences such as a delayed diagnosis or delayed preventative care was also intertwined with how other dancers discussed the value of health insurance in their life. Vivian describes learning a lesson about preventative care through her troubles with dental work and antibiotics about 4 years prior to our interview:
I was recently schooled in how important preventative care is because [the lack
of] it caused me to become sick and I had to take about two years off. I was really
sick with pneumonia and a whole bunch of other stuff. I was going along pretty
well till about 46 and then I started to get all these dental infections; I hadn't been
going to the dentist because I didn't have the insurance and I couldn't afford it…I
could not afford to go get a cleaning. I now realize that I should have found a way
to just do it because it cost me a lot more in the long run with root canals and I am
missing a tooth now…I had to go to the dental school which is about half of what
a regular dentist would cost, but the filling kept coming out. The students
wouldn't do it correctly even though they are supervised. I had one filling that just
kept coming out and coming out and coming out; I think they were doing
temporary fillings…it was a nightmare. I had to take antibiotics for all of this and 164
what I discovered after was that antibiotics kill off the healthy bacteria that keeps
you from getting sick. That led me to get bronchitis and pneumonia for seven
months; I think there were three weeks in there when I wasn't sick. The physical
therapy that I [have done] this past year is a direct result of that; I wasn't dancing
so everything became weak and when I started dancing again, I had one injury
after another. I wasn't strong enough to be doing all the dancing I was doing then.
It's been this chain-of-effect thing that’s brought me to having the Achilles injury,
this neck and shoulder thing, and just being weak being overdeveloped in one area
being weak in another.
On a spectrum of gaps in coverage to continuous coverage Vivian, Benjamin, and
Jane had the longer gaps in coverage of the American dancers I spoke with. Jade expressed that she’s “never been a fan of the medical profession” who has said that
Planned Parenthood is “pretty much ‘it’” for her in terms of medical care; she noted “it’s part of the reason I’ve never had health insurance, I am not going to see a doctor even if I can afford it, I am not going unless I really have to”. Her “really have to” came about a few years prior when she suffered an Achilles tendon rupture during a rehearsal and spent several weeks working to obtain an appointment in a dance injury clinic in New York
City. In this clinic, she qualified for their free program and was able to see a physician and physical therapists at no cost to her. When I inquired about her current health insurance status, she noted “I only got health insurance when the penalty outweighed the cost of the healthcare”.
Speaking more neutrally about having health insurance, a few of the American dancers appreciated their standing. Olivia recognizes that she has been paying into her 165 new health insurance from the PPACA, for about 18 months at the time of our interview and finds it useful for getting her medications at the discounted rate of “seven dollars a month”. Olivia otherwise hasn’t used her health insurance and has been on medication for arthritis/gluten intolerance since she was 19. Moreover, Fern who at the time of our interview was still qualified on her parent’s plan noted “the massage therapist I was seeing didn’t take my health insurance and cost about 35 dollars which definitely adds up. It was worth it. I think those were the only times I paid out-of-pocket for healthcare”.
She did express feeling unprepared financially to purchase her own health insurance after she no longer qualifies. Finally, Coral who was able to stay under her parents’ plan until age 29 due to a New York State law and then transferred to her own health insurance plan under her full time employer expressed “I am pretty rare to not have a lapse in coverage at all but I think I am also pretty rare in not really using my coverage ever”.
The Patient Protection and Affordable Care Act. During the time of many of the American interviews, new healthcare policies were being proposed in Congress to repeal and potentially replace the Patient Protection and Affordable Care Act (PPACA) also known as “Obamacare”. The United States put the PPACA legislation into effect in
2010 to make health insurance more affordable for Americans. Vivian was the only dancer interviewed before the 2016 Presidential election. Four American dancers noted that it (or it’s legislative muse MassHealth) made health insurance affordable for them, several were neutral, and one dancer noted the PPACA’s Medicare expansion created a greater expense for her and her family. Zoe, a single-mother and a co-company owner confided: “as an artist I don’t make a lot of money, so I’ve been able to qualify for tax credits and have been able to insure myself in a fairly affordable way”. 166
Jade had been able to afford health insurance from the government-supported marketplace for the first time just two months before our interview “last month is when I first had health insurance as an adult”. She expressed a particular stress: “with the current political climate, I have been checking my phone every hour for the last couple of days to see if I have health insurance at the end of the day”. She further reflected that while she was working as a dance teacher, the Obamacare marketplace offered her healthcare for 97 dollars USD premium each month which she considered unattainable for her income. It wasn’t until the dance studio closed and she lost her job that the fee was reduced to about
3 dollars USD a month and she felt it was “worth it” compared to the tax penalty.
Gaining insurance for Jade was also an issue. In speaking about enrolling under the marketplace, Jade recalled “I couldn’t get into the website [for] the first year, the second year I was able to add my information but couldn’t see any plans, every year I got one step further in the process”. However, Jade also noted “the health insurance is crap, but if
I run out in the street and got hit by a bus it would be better [than nothing]”.
In a similar way, Vivian afforded health insurance this way: “I got MassHealth for free because I make 16,000 dollars or less which is considered below the poverty line so
I’ve had free health insurance from Massachusetts since 2011”. Vivian noted she didn’t know about MassHealth until a social worker, who she was speaking with for an unrelated issue, informed her of it. Where Obamacare made health insurance more affordable for Jade, Vivian, and Zoe, it did the opposite for Nora who was recently retired from teaching tap dancing full time. Nora exclaimed that her “premium coverage went up
300 dollars after Obamacare, it’s ridiculous, we pay more for Medicare per month than 167 we ever paid for health insurance. We are being taxed because we have a better plan than some people”.
The change in national healthcare policy forced Quinn to change plans, she remarked “what I find an issue [with] is that because healthcare is switching, you have to have this paper trail of copays, referrals...I think it’s insane to keep track of and hold on to”. She noted that with the temperamental health policy environment in 2017, she added:
I am clear that [health policy legislation in the United States] is going to keep
shifting so to understand what is maybe going to happen is a waste of energy; but
being informed about this is and what they are thinking is crucial.
Olivia also expressed a concern with the new marketplace:
I have coverage but it’s just so complex and complicated to use. With Obamacare,
they assign you a provider who has a million other patients so to get in and see
them takes six months and then you have to get referrals, it’s just very much a
hassle.
Between adapting to a new marketplace for health insurance or anticipating shifts in policy, about half of the American dancers expressed anxiety to some degree about health insurance in the United States.
Australians and Health Insurance
All Australian citizens have public health cover, Medicare, while they have the option of purchasing private health insurance (often called health cover) that allows access to private healthcare services such as private hospitals. Four Australian dancers solely relied on Medicare (Yasmin, Kat, Piper, and Una), three dancers’ private health insurance was sponsored by their employer (Emerson, Liam, and Alynn), Gwen was 168 covered by her parents’ health insurance policy, and two purchased their own private health insurance (Harper and Ida). Ida commented on the system “I don’t think anyone should be turned away from healthcare if they need it and the public health system should be better funded; if I am paying tax, I would like my taxes to go there and not [to] defense". In thinking about Australia's health insurance scheme, Gwen shared some thoughts regarding her experience of healthcare in Germany and the United States; she noted:
Compared to a lot of other countries, we have a relatively good healthcare system,
I mean everyone always complains about not getting enough back from their
healthcare, but I think that is probably just a human thing that we would all like to
get more back.
Considering healthcare in terms of being a dancer Liam noted if a dancer lacks private health cover they:
Are in a situation [where] they don’t feel safe enough to be able to push [for] what
they want and then you may not be able to achieve the results that an artistic
director wants...the benefit of being in a company and having insurance is having
a physiotherapist and a medical team...I wouldn’t not want that in a company.
Yasmin learned most of her ideas of health insurance from her mother or adverts on the internet and TV. Notably in the time before our interview she noted some adverts on the TV “pioneering to get people health insurance”. In a similar sense, in trying to understand the details of Ida’s private health cover, we came to a point where she did not think she “had enough cover” to go to a private hospital; “I am probably just showing the squalls in my understanding” she said, continuing to say “I mostly see the benefit of 169 rebates for dental and optical work”. Neither of these dancers expressed a confidence in their knowledge of health cover.
Private and public cover. There are several healthcare differences and similarities between American and Australian healthcare policy and norms; the largest being that all Australian citizens have access to basic healthcare through taxation called
Medicare. Similar to American healthcare policy, Australian young adults may stay on their parents’ private health insurance (often referred to as private health cover) until the age of 25 in Australia. There is also a concept called “bulk billing” that several dancers elaborated on for my own understanding. The greatest question to begin was whether the dancers were on private or public health cover and what were their thoughts regarding either system. This concept was demonstrated well with two stories coming from Kat and
Yasmin. Yasmin tells the story of her first time receiving care from a public hospital soon after she aged out of eligibility to be covered by her parents’ insurance:
I didn't have private health insurance so I was thinking Oh no what's going to
happen, what is it going to be like? Everyone was in the emergency ward and I
was a little bit scared because my mum's always had private health insurance, I
didn't know what to expect. It was actually amazing, I got in there and was in a
ward with all these other people but I could pull the curtains so that it was private
and the treatment, the staff, and the operation were amazing. That was a really
positive experience.
Compare this experience to Kat, who also did not have private health cover:
I have been having gastric intestinal issues, so just seeing a general practitioner
and figur[ing] out what was wrong. [My general practitioner] sent me to a 170
specialist and he wanted to do all these tests and stuff, and said you can go public
but you have to wait three months or you can pay for it and I can see you in two
weeks. So of course, I asked what he thought I should do? [He replied] Well it
could be really bad so you can't wait three months so, $3000 later.
Kat ended up paying the 3000 dollars for the testing and procedures out-of-pocket. It was not feasible for her to purchase private health cover at that point because the waiting period is about 12 months. These two stories demonstrate how relying on public cover can manifest. Yasmin noted that her public hospital experience compared to a lifetime of private cover experience was equal in her own satisfaction whereas Kat’s experience left her seeing the financial benefit of purchasing private health cover: “it costs roughly 100 dollars a month...the maximum I would have had to pay [for her GI issue] was 500 dollars, so I think probably I am still trying to think about that, but it probably is worth it” said Kat.
Moreover in regard to Yasmin’s experience, when she was nearing the age of 25,
Yasmin and her mother “went into a panic and thought quick, before the healthcare runs out!” that they should take care of her lingering healthcare needs. Yasmin weighed the positives of private healthcare as the ability to have a room of one’s own, to skip ahead on organ donor lists, and choosing the doctor. In her words “whereas with public, we’ll put you on a waitlist and when it comes time you’ll have this doctor”.
Harper has always been on private health cover, she noted that sometimes she used her public health cover - as an example she had recently done so for a cyst behind her knee. She noted that she “went through the public health system when I could have gone private and that was quite a distinct choice because I was able to have really great 171 public healthcare”. Even with expressing the positives about public health services, she buys private health cover and thinks the premium for her health coverage is expensive.
She said:
Because I am poor, I don’t pay for the doctor and sometimes with scans and stuff
I don’t have to pay too much out-of-pocket, but everything else costs money - I
have private health insurance but it doesn’t really cover very much including the
people I want to see.
Many dancers, both American and Australian, shared the experience of “aging out” of eligibility to remain on their parents health insurance cover. Kat, appearing in her late 20s, noted “I find that it is not uncommon [that] people my age don’t have private health insurance because of that exact reason, they come off the family one and then have done nothing about it”. Ida noted that she had a one-year gap between leaving her parents’ cover and buying her own private health cover exclaiming that the cover she affords “is definitely nowhere near what I had with my parents”. Harper stayed with the same insurance company that her parents were on; she noted this was for reasons of convenience and speed. She notes it was “too easy” to sign up once she had turned 25; furthermore, she said that her decision to not stop subscribing to a private healthcare time was half encouraged by her mother and more just what she felt that she wanted to do.
Gwen, who was still under 25 and covered with her parent’s health insurance, said in respect to being questioned about her plans to buy or not buy her own when the time comes: “I haven't really thought that far ahead, I think it probably depends on my work situation at the time, whether I can afford that or whether, I guess priorities at the time, if
I feel that I need it”. 172
One dancer kept in respect that health cover doesn’t always cover all the costs of services needed. In his story, Liam reflects on the financial sacrifices his parents made to afford him treatment from a lumbar spine specialist who worked with a major Australian ballet company; he went on:
The worst thing was the cost that came to it, and even though having something
like Medicare in Australia, was beneficial, there was still a few specialist
appointments that we had to pay the full price...that obviously costs a lot of
money and I don't think there is one moment where I’m not grateful for what both
my parents were able to offer me.
Kat and Yasmin also commented on parents helping them out with additional out-of- pocket costs that were out of reach for their income at the time.
Freelance and company. Several of the Australian dancers were or had been in a company that offered levels of support with healthcare, ranging from private health cover or in-house physiotherapy to workers cover. At the time of the interviews, Liam and
Emerson were the only participants employed full-time as dancers in companies that offered a comprehensive package of healthcare cover. For them, most medical services are in-house, complimentary services unless they seek a medical doctor or imaging services. Moreover, many of these services offer walk-in hours. However, in Emerson’s case (being a French citizen and an immigrant in Australia), this status does not entitle him to the public healthcare system. He shared some thoughts on the matter saying:
I live in Australia, I offer my expertise to Australia and I am happy to do that and
it sounds very pompous but it’s sort of what it is, the audience that I dance for are
Australian, so that’s who I give my art to and I fight with [the fact] that I have to 173
pay that much money every month just for the only reason of being from a
different country.
For Ida, who works full time at a community dance-company, enjoys the benefits of private health cover through her employer, she said “everything is handled”.
Somewhere between the freelance and companied dancer there is the student.
Liam described the following scenario in which he struggled to access healthcare and came out the stronger for it. While studying in Europe, Liam was in a full-time dance school that offered in-house physiotherapy however, the group prioritized care for the dancers in the affiliated professional company, which he was not a part of. After sustaining an ankle injury and finding it difficult to get attention from the physiotherapist, he brought himself through his own rehabilitation. He reflected “I had to learn how to self-manage my own body and my own injuries”. This story demonstrates that even when having access to in-house physiotherapy, the reality may be different and moreover, at what point do dancers take over their own healthcare?
Freelance dancers may purchase their own health cover, utilize the public
Medicare healthcare system, or consider Workers’ Cover when signing contracts. Piper, a freelance dancer who has always been on the public system, stated:
I have been luckily quite healthy, I could have been paying private health
insurance for the last fifteen years and haven't. [I’ve] kind of benefitted from that
because that would have been a pretty huge expense, at the same time, I think as I
get older and having children I think probably the next stage of responsibility is
probably to get on private health insurance. 174
She noted that when she turns 30, she and her partner will need to consider the Medicare tax they may face; she noted that they “decided not to worry about it...that in the long term it doesn’t matter”. In terms of being a dancer, Piper said “as a contractor, I am supposed to have my own health insurance so that if something does happen at work, I can cover my own”. In spite of this, Piper does not have her own health insurance so she stays aware of when contracts offer Worker’s Cover. This is in contrast to Ida’s three freelance dancing years, when asked if securing a contract that includes work cover was important for her she responded “I probably didn’t have an awareness of that”.
American Dancers Access to Healthcare
Access to healthcare includes the dancers’ reflections on needing help with physical, emotional, or mental issues and the ways that dancers were able to facilitate receiving care along with those factors that hindered their ability to receive care. Barriers encountered was further broken down into specific smaller themes which include: cost, insurance coverage and referral, and within dance factors and scheduling.
Seeking healthcare. Each American dancer proposed a unique reason explaining why seeking care may be challenging or easy for them. Olivia and Coral both noted they avoided making appointments based on poor relationships with medical practitioners and the cost. Coral noted that she “never had a doctor that remembered [her]” and moreover that it doesn’t make sense to make an appointment when ill because she finds the wait times outlast most illnesses. Olivia feels the cost is always more at the time of billing than at the time of inquiry of the cost and that seeing her gastroendocrinologist was “200 dollars just to see him”. Olivia also illustrated a mental barrier and successive growth she faced when she suffered a second metatarsal injury while dancing in her freshman year of 175 college: “I didn’t realize it was a stress fracture because they told me I wouldn’t be able to walk, it would be too painful. I didn’t even know, I just thought it was sore...now I know the warning signs”.
Quinn and Zoe shared factors that enabled them to seek care: For Quinn, during her time performing on Broadway, she was designated a physical therapist she could work with and her doctor’s visits were paid for by the shows she was working on. Zoe made it a point to go to physical therapy when her rehearsals led to a show and there was a need for additional strength. However, similar to Coral, Zoe remarked “I am not someone who is going to the doctor when I am sick” noting that she stays up on preventative care and avoids “a ton of interactions with physicians”. The American dancers were sensitive to the impact money had on their ability and willingness to seek care.
Barriers encountered. Barriers encountered are factors, internal and external to the dancer that stood between the dancer and their ability to receive good care. Good care is the level of care that was wanted or expected by the dancer from their point of view when telling their stories. After assessing all of the barriers, several patterns emerged: 1. costs, 2. insurance coverage and referral 3. within dance factors and related, scheduling.
Together, these factors made accessing quality healthcare difficult, hindered, or impossible for dancers.
Several obstacles were named that made it difficult for the dancers to either gain health insurance, access healthcare, or both. Some of the obstacles came about from the
PPACA legislation in regards to enrollment, increased costs, or overly complicated new coverage. Other obstacles the dancers reported were lacking the ability to afford health 176 insurance at all during a period in their career. Moreover, other dancers found that out-of- pocket costs added up for the uncovered services they desired or that their lack of knowledge about health insurance was a barrier between them as utilizing services.
Costs. For some dancers, understanding the complexity of insurance wasn’t as big of an issue as its unaffordability. Benjamin noted that before obtaining a full-time job in an institution of higher education, he had no health insurance at all. This followed him through his time in Boston, New York, and Paris. On the other hand, another dancer who does work at a university and still does not receive benefits, Zoe, noted “I don’t have a full-time faculty position, I have a three-quarters position which means I don’t get any of the benefits so I have to buy my own, and yeah, it’s a terrifying time”. Finally, Vivian noted that after leaving her full time job she was uninsured because she found a COBRA
(Consolidated Omnibus Budget Reconciliation Act) plan “just impossible to afford”. I asked Jade, a freelance dancer, about the potential of Worker's Compensation from the companies she has had short-term contracts with and she replied “nope, zero, zero, never happens”. Even for insured dancers, they made note of their out-of-pocket copays saying that they “added up” or that they were “their biggest healthcare expense”. For Olivia’s
Crohn's disease status, she sees a gastroendocrinologist. This specialist is not covered under her Obamacare market plan so she ends up paying out-of-pocket for those visits.
Oliva remarked “it’s 200 dollars just to go see him and get prescriptions and blood work done, it’s frustrating”. Moreover, she also purchases visits for her acupuncturist and massage therapist out-of-pocket because they are not covered services.
Eight of the American dancers commented on healthcare expenses being a prohibitive factor when considering their income as dancers. Benjamin called his early 177 dance earnings “barely making a living” and Jade felt that even with recent PPACA subsidies that it was “still unattainable” for her. She had a surprising story when driving this point home:
I had a problem with my tooth and it was cheaper for me to get on a plane, fly to
London and get my tooth fixed there then to go down the street [in New York
City] and get it fixed, including the cost of the plane ticket.
She noted the whole procedure was “30 quid” including medication. Freelance dancers, Vivian explained “are usually putting together a living with multiple teaching things and freelance dancing...I myself am only teaching for [a Massachusetts college] and am making just 5000 a year”. Quinn, Zoe, Olivia, and Fern each expressed that cost of healthcare services had specifically prevented them from making an appointment in the past for a service, including mental health counseling. A surprising finding was the number of dancers who had stories about seeking dental work from dentists in training;
Vivian who struggled with a cascade of injuries which stemmed from a dental health event, had a particularly bad experience with this resourceful maneuver.
Insurance coverage and referral. For the dancers affording insurance policies, they presented alternative barriers encountered and spoke about prohibitive out-of-pocket costs, confusion about the extent of covered services, and problems with relying on referrals. Two American dancers remembered specific costs of past services they purchased (250 dollars for orthotics) or didn’t buy (150 dollars for an hour long counseling appointment). Quinn expressed frustration about the logistics of switching health insurance companies noting that she wished for clearer instructions regarding how to change primary care physicians; she said “some of it is my fault; it’s not what I do so I 178 don’t understand, but this could be [made] a little smoother for everybody”. In a similar vein, choosing plans proved difficult for Jade, she expressed “I’d never had to choose a plan, I didn’t know what it meant, I never had to look at it before because it’s not my world”. To add to the complexities of navigating insurance, Vivian recounted an event where her insurance company falsely claimed she was out of covered physical therapy visits; ultimately, her physical therapist had to mediate between her and the company because she was getting the wrong information. Finally, many insurance policies in the
United States rely on a referral system stemming from the popularity of managed care in the 1980s which placed the responsibility of case management on the primary care physician; this can often be a barrier for a dancer who lacks a primary care physician.
This proved to be a barrier for Jade when she was trying to obtain an appointment at a dance medicine clinic in Boston, “they said oh we can’t see you, we need a referral. I
[didn’t] have anybody, I just fought every day to get in there”. Sam noted an additional difficulty and mentioned a dissatisfaction with his insurance company: “they make it difficult for whatever reason to switch doctors...they really don’t want you to”. Both Sam and Vivian expressed that receiving more referrals from physicians would improve their appraisal of them; Sam noted disappointingly “the amount of referrals [he has] gotten is about zilch” whereas Vivian said she “had a great doctor who will always send me to a physical therapist when I have something going on”.
A particular obstacle that stood out was the customer service experiences and interfaces that the group encountered when trying to either enroll in health insurance or to figure out their health plans. For freelance dancers, providing an accurate statement of income was an issue. For example, Zoe found the online enrollment process confusing; 179
“because I am an artist with different sources of income, the template that was provided did not work”. She ended up having the website miscalculate her financial status which resulted in offering no tax credits to aid her in affording health insurance. Moreover, Zoe noted that in her state, there is no physical office she could visit to get face-to-face assistance so after a “long phone call on-and-off hold” she managed to qualify for a plan and began paying only to learn four months later that she was overpaying and lost about
1,500 dollars of income because of the error. Her more recent problem with health insurance is that her company had not sent her the new health insurance cards that she needed to book an upcoming surgery for her knee. Zoe expressed that without knowing who to speak with, the consumer is at a loss to move forward with his or her healthcare:
It’s so frustrating, nobody seems to know how to help you…that’s the frustration
with the enrollment process. You feel like a cog in a really big machine and it
would be nice to feel like it’s a little more personal, but it is what it is.
In a similar vein, Jade submitted a single paycheck, from a one-time job at Harvard, that her state health insurance program “extrapolated into a full time job” she could not convince them otherwise. She ended up getting a lawyer from an arts advocacy group who went to court and won on Jade’s behalf. Once insured, understanding coverage is confusing for Vivian who noted “I still don’t understand how my insurance works, they send this huge manual that nobody ever has time to read”.
Within dance factors and scheduling. Five American dancers expressed how some element of dance culture or being a dancer specifically affected their ability to access treatment or care. “A dance teacher being irresponsible with dancers’ bodies” and
“a cold theater” were examples Jade and Coral gave of times they felt their injuries came 180 from dance. Nora was a teacher in a musical theater program in a performing arts conservatory and she noted that the in-house physical therapy services were not available for her students: “my kids couldn't’ access it either, they were told it’s for dancers and the dance majors got priority”. Moreover, Nora noted that when she was injured, she was expected to pay out-of-pocket for tap dance teachers to fill in for her classes. Oliva noted that in a time when she needed care while dancing for a major ballet company, that “it was a very touchy thing if you were going to physical therapy; she [Olivia’s choreographer] was never good about prompting dancers to get help”. Olivia went on to say that it was because of her seeking care for her injuries, eventually having a surgery, that she was not offered a contract renewal with that company the following year.
Sam noted that because of his company’s rigorous tour schedule he is “just never here...it’s impossible if they don't have an appointment during these two days” that he is back home from touring. Scheduling was also an issue for dancers. Some dance specific doctors hold their practice in different locations, making their schedules at any one location more restrictive. “It’s really hard to touch base with these doctors when they are not always in Boston” said Fern, who also expressed that even the time she does have with doctors feels too short. Ben noted that he sometimes has to wait three weeks for an appointment with his insurance while Jade told of waiting six weeks to see a physical therapist in a New York based dance medicine clinic, one that she was able to see because of their sliding-scale payment option.
Facilitating factors. Dancers also identified several factors that aided their ability to either be insured or to access healthcare. Quinn and Sam are two dancers whose full time involvement in their craft offered them healthcare on-site (Quinn) and 181 comprehensive benefits (both). The other American dancers accessed healthcare or health insurance through marriage, non-dance full-time work benefits, school provided medical services, being thrifty with their care choices, and sliding scales. Nora, a retired conservatory-level tap dance teacher, stressed that she always tried to pass on the “buzz words” to her students that would increase the streamlining of their seeking healthcare.
Having a doctor for a husband was a major facilitator of medical cover in her career and life, but she felt that besides that connection, a knowledge of the healthcare system was important for dancers to grasp.
First, Quinn and Sam: Quinn is the only Broadway dancer that was interviewed for this project. Her experiences of being a part of a union are unique to her stories. After naming several work-related injuries (hamstring, knee, and patella) she expressed the level of support she had: “I saw a doctor for all three which was paid for by the show and their insurance”. Through a referral she began working with performing arts-specific physical therapists and noted she felt spoiled: “I thought this was how the world worked.
At that time, I paid under 200 dollars every quarter for full health, full vision, full dental, and you could get glasses or contacts”. The downside to the support she got while a part of the show was that she noted she did not know how to deal with health insurance when she stopped performing in shows and had to find it for herself. Although, she provided the resources she and her husband used: “we went through a Freelancer’s Union…it’s
[so] people who are freelancers who aren’t covered by a specific job can get insurance, dental care, all those different kinds of things”. Moreover, she notes that they’ve been lucky in the resources and help they’ve had in affording insurance aside from just one two-year period. 182
Sam, a full-time, professional contemporary dancer, quoted two sources of financial protection for him that have facilitated access to healthcare professionals. In the interview, Sam noted:
Anytime we are injured at work there is Worker’s Compensation and we have
great worker’s comp…I also have a company provided HRA (Health
Reimbursement Arrangement), it’s a prepaid debit card basically that I use for all
healthcare expenses up to my deductible. There are very little out-of-pocket
expenses.
Moreover, he added that his company provides up to five paid appointments a year for physical therapy.
Aside from the professional company level, some of the dancers experienced having access to medical services as an undergraduate student dancer. Fern explained that she felt lucky because she’s always lived in a “dance medicine hub” and that her undergraduate conservatory offered in-house physical therapy services on a drop-in basis.
Moreover, the school’s Physical Therapist was also employed by Fern’s performing arts high school, so she had benefited from a continuous relationship with that clinician.
Moreover, during Sam’s time as a dance student at a liberal arts college in New
Hampshire, he could be evaluated by one of the school's Athletic Trainers. He explained:
It was a good eye-opener to me that you didn't have to go to a hospital to get
care...it was an evaluation that let you learn about your body in a way that you
could take that knowledge and apply it in a way that's preventative or treatment
for an existing injury. 183
Jade also had athletic training services available to her while a college student; all three dancers noted that these services had no out-of-pocket cost to them.
Several dancers had health insurance policies through their spouses and in Zoe’s instance, she was allowed to stay on her policy after divorce until her ex-partner remarried. Zoe reflected:
When I was married, I had health insurance through my husband who worked, he
was a teacher and worked for the state of Massachusetts so I have good, well not
good, we paid a huge premium, but I had healthcare that I didn’t have to pay for.
We had a family plan with children and he was able to cover me after we divorced
until he got remarried.
Benjamin noted that his partner’s desire to share their work related benefits with
Benjamin was a contributing factor in the ultimate marriage that resulted between them.
Uniquely, Nora was married to a physician in Boston and enjoyed health insurance through his employment and moreover the benefits of being personally connected to specialists in the Boston area.
Other dancers, including Zoe, found that staying on their parent’s health insurance was helpful in maintaining insurance through their youth. She noted that her mother paid for her insurance during the gap between disqualifying for her parent’s insurance plan and her husband gaining health insurance for his family. Coral noted that a factor that has enabled her to have no gaps in her insurance coverage was a law specific to New York
State which allows young adults to remain on their parent’s health insurance until 29 years of age, three years longer than the federal legislation which mandates insurance companies to cover young adults until the age of 26 on their parents’ policies. 184
Fern who was the only American dancer I interviewed who was still under the age of 26 and thus covered under her parent’s health insurance policy. Fern was also working for a retail company in Manhattan that offered health insurance to their employees that
Fern acknowledged could be an option for her after she ages out of eligibility. Having a non-dance full-time job or part-time moonlighting employment was also a way some of the dancers went about securing health insurance. Olivia who was a professional full-time ballet dancer for several years in New York noted that she and several of her dancing peers worked a part-time job for health insurance benefit.
A final discussed factor that aided in lowering the financial barrier of healthcare was sliding scales. Several of the dancers who sought care from a certain New York City dance medicine clinic noted that it was their sliding scale that made it financially possible for them. Jade commented “I am a poor dancer but [the administrators of the dance clinic said] that’s okay, this is what you’ll pay and that was it. If I didn't have that I don’t know where I would have been”. Jade made note that the organization Planned Parenthood also offered a sliding scale, but that they are “shooting themselves in the foot” because they ask for two recent paychecks; Jade feels that because she is freelance, these two checks are not representative of her yearly earnings, and thus feels as though she’s given an unfair advantage.
Australian Dancers’ Access to Healthcare
Access to healthcare includes reflections on the dancer’s reaction to needing help with a physical, emotional, or mental issue (seeking healthcare) and the ways that dancers were able to facilitate (facilitating factors) receiving care and the factors that hindered
(barriers encountered) their ability to receive care. Barriers encountered was further 185 broken down into specific smaller themes which include types of isolated circumstances and within dance factors.
Seeking healthcare. Within the ten Australian interviews, a disparity was perceived between companied dancers and freelance or self-employed dancers. For companied dancers, waiting 3 to 4 days to seek care for pain, or having a complimentary massage once a week for maintenance was routine. Emerson noted that there is not a culture of hiding pain in his company as there is for most dancers, he stated:
Some people will always hide their injuries, maybe because they don't want it to
impact something or maybe they know how to manage it so they stay quiet; but
many others go to see the physiotherapist if the injury is a bad injury and it
impacts their dancing and their work to the point of modifying things; but there is
not that culture of I will not go see anyone, ‘cause, I don't want anyone to know.
Gwen was retired from a professional ballet company when we spoke, but she had danced with knee pain for years prior to her tenure at a large ballet company; she sought out treatment during that year and had surgery to correct the issue (jumper’s knee) after her contract ended.
Freelance dancers in Australia were vocal about the hesitations they had to seeking care; appointment wait times, additional costs, and the financial pressure to keep dancing translate to less willingness to seek care. This in turn implied or suggested that freelance dancers therefore seek treatment for pain, injury, and mental health reasons at a higher threshold than companied dancers. For example, Harper who sustained a knee injury that showed significant swelling the night that it happened, waited two months to seek professional help. Additionally, Piper expressed that as an independent dancer, not 186 always knowing the “right kind of health professional to go to” for any particular ailment was a barrier. She reflected on how age changed her perspective when she said “when I was younger, I would leave injuries and not see someone or get proper treatment, but in the last few years, I am really respecting rehabilitation more”. Alynn spoke about having a great awareness of her body and of recognizing that she may have a high pain threshold and stated that even when she recognizes that she is injured she “feels so lucky to have a job” that she “puts pressure on [her]self to keep going and work through an injury as opposed to seeing the injury for its seriousness”. Kat felt a time and monetary restriction in the past to seeking care she noted “I would go to the physio when I was injured, I would still have massage therapy once a week for maintenance”. She continued “we were all really poor and we didn't have any money and danced 60 hours a week; we didn't have enough time to earn enough money so [we] could only pay for those things when we desperately needed them”.
Barriers encountered. The Australian dancers presented individual barriers encountered ranging from practitioners’ clinical skills, to location, to dance culture. One out of the ten Australian dancers noted money as being a barrier to care, but specifically speaking about complementary practices such as massage and the Feldenkrais method.
Ida noted that the private health insurance company that she was a customer of was
“basic” and “nowhere nearly as good of a plan” as the one her parent’s had which she was able to stay on until the age of twenty-five.
Isolated circumstances. Ida, who lived in a remote location outside of Darwin, noted that she struggled with receiving proper care in a timely manner; such as the time when she saw a nurse for a facet joint dysfunction noting “she didn't have a great 187 understanding of what was going on but gave me strong painkillers which got me through three weeks of performance until I managed to travel to Darwin to see physio with a dance medicine background”. Even while away at school as a dance student she perceived no support for the physical or mental side of dance, she noted “it was a sense of leave all that at the door, you are here to do the classes”. Emerson, one of two active companied ballet dancers in the group mentioned that being on tour was when he had limited access to the in-house physiotherapist and massage therapist. As a student,
Emerson recalled that while studying in Paris he was told he has access to the affiliated company’s physiotherapists, but he found in practice they prioritized the professional dancers leaving much of his rehabilitation to be self-directed. Either as a student or living in a rural location, these two dancers limited access to healthcare was specifically circumstantial.
Within dance factors. More often reported were dance-related factors that kept the dancers from receiving care when they sought medical attention. For example, two dancers noted that not having an understudy or having the pressure to keep performing, kept them from seeking care when they identified a need for it. Alynn commented on the pressures of dancing in a small company, and therefore, not having an understudy: “there is not an option of opting out and not performing during the season, there is pressure and stress on the dancers to be in peak form at all times”. Compare this situation to Harper, a freelance dancer in Sydney who injured herself while dancing for an independent film:
I twisted my knee and it swelled up to the point that I couldn’t straighten it...there
were about thirty people there to film, so for me to say I have to stop...I didn't
know how and I was in shock as well, I held off. 188
Harper ended up “holding off” for two months while she continued to massage and ice her knee until ultimately seeking care from a physiotherapist and being diagnosed with a partial posterior cruciate ligament (PCL) tear.
Facilitating factors. Access to healthcare is discussed in terms of the factors that helped dancers receive care; several factors were identified such as being employed by a large company, budgeting, being thrifty, and asking peers for reference. For the companied dancers, several services were exclusively available such as in-house physiotherapy with walk-in appointment times and having access to a larger health team.
Emerson described an easy process to accessing care: “I have access to so many health benefits...I don’t have to go fetch out healthcare anywhere else but at work”. Liam noted that he enjoys a complimentary massage from a staff massage therapist on a weekly basis, which had become a part of his physical maintenance routine. Harper is a dance teacher within a large dance company and as such receives discounted access to the company’s physiotherapist; she noted this access is very helpful for her despite having developed an unfavorable regard for the particular physiotherapist at the company.
For freelance dancers, Worker’s Cover was a possible route to affording healthcare services. Sometimes employed through a contract that includes worker’s cover, Piper mentioned that “once you are covered, everything from your vitamin table to massage oil is covered”. Parents were also a resource of making medical decisions and affording medical care, especially for large or recurring out-of-pocket costs. Liam reported not perceiving any barriers to healthcare in his career aside from in his youth when his parents paid out-of-pocket for a dance-specific lumbar spine specialist who was employed by a large ballet company. Gwen noted that it was her family who supported 189 her emotionally when she was deciding what to do about her jumper’s knee, “someone to talk to to gain another viewpoint of what you should do”.
While working as a graduate student in a graduate level dance company, Yasmin described education to be a facilitating factor. She recalled that she and her peers were given a lecture about how to eat healthy on tour with a limited budget: “we weren’t given much [money] at all, but we were told how to live off of [that amount] and how to feed ourselves beneficially”. Likewise, in his teenage years while seeing a physiotherapist for a back injury, he felt that he should use every session to learn more about his body and preventative measures to build into a personal self-care routine.
Alynn noted that during her career as a freelance dancer her jobs were “working a couple of weeks and then not working a couple of weeks”; therefore, keeping a budget was a strategy that allowed her to afford healthcare. This pattern forced her to manage her money, which she felt was difficult, but she also said that when she does have an injury or feels she needs to see a clinician for maintenance that she values having the resource to pay for that service. Being thrifty was another way the Australian dancers described taking care of their own health. Harper specifically showed me her collection of
Restorative Yoga props such as bolsters and blankets that she had purchased over time.
She noted that classes are expensive and that she felt capable of doing the poses on her own time at home. Considering insurance premiums, Alynn assured me that her private insurance policy was one of the cheaper policies “aimed at the young people” and it allowed her to take a percentage of the cost off of her treatments such as massage.
Finally, utilizing medical references from peers and other dancers was a strategy that Liam described. He reasoned “it costs more in the end [to go] to someone bad to then 190 getting someone good” and felt that doing the work to find well renowned medical professionals was a better use of resources. He continued “word-of-mouth
[recommendations] have been very vital within healthcare. That is how we found my
Pilates guy who was also an ex-Australian Ballet Company dancer”.
American Dancers’ Reflections on Care
Reflections on care discusses the negative experiences and positive experiences that dancers shared during the interviews. In the re-telling of the process of injury including the diagnosis, treatment, and rehabilitation, the dancers would often offer their own appraisal of the services, making clear what was favorable or not. Moreover, under the reflections on care, communication with medical professionals was prominent, therefore it is discussed separately and speaks about themes of bedside manner, appropriate language level, and bluntness.
Negative experiences. The majority of American dancers made comments such as “I never had a doctor that remembered me”, “[doctors] don’t always have the appropriate amount of time for you”, and “he wasn’t really paying attention...it seems like they are reading the newspaper”. These comments demonstrated a frustration with feelings of not being given time or attention from the medical professional they sought help from. Vivian painted a scene demonstrating a time she felt ignored whilst in physical therapy: “it’s frustrating to work with them when they are talking about movies or whatever. I was doing the exercises and just went home...I found out I was doing [the exercises] wrong two or three weeks later”. In a similar vein of frustration, Vivian also expressed that with an injury that spanned two decades, she has little faith that medical 191 professionals can accurately diagnosis her, and her experience alludes to using “Band-
Aids rather than get[ting] to the root to what is mechanically going on”.
Considering actual treatments received, Sam, Quinn, and Olivia felt they were not receiving the quality of treatment they expected. Sam expressed that the support he has access to “doesn’t seem to support someone at my physical level”, acknowledging that physical therapists without specialized training have difficulty rehabilitating a dancer back to the high physical level of performance he needed. Compounded, Sam also noted that he has never been referred, which would be a channel he had hoped could lead to more appropriate care, he stated:
People want to do whatever it is that they do to you regardless of whether it is the
right thing...they want to [perform] surgery on you if that’s their thing, they want
to give you a steroid shot if that’s their thing...it often comes as a suggestion
before all the relevant information has been disseminated.
Quinn and Olivia had experienced in physical therapy a sense that they were being put on different pieces of equipment so the therapist, could “check it off and get paid”.
Moreover, Olivia felt that many of the therapists she had worked with “were not great with dancers” and “didn’t have any imagination or variation...so I often felt that I was not getting the care I needed”. Four American dancers experienced a specific negatively appraised treatment and explicitly mentioned it in the interview, these were: expensive, painful, and ineffective orthotics, an error with a spinal tap procedure, and dental fillings that repeatedly fell out.
Considering more systematic levels of medicine (clinics, hospital departments, pharmacies, and insurance companies), complaints and grievances were more focused. 192
The top issues with medical clinics and hospital department were around scheduling, dancers didn’t feel that their doctor had enough time. On one extreme end, Fern experienced a physician telling her he had surgery “across the street in five minutes”, leaving her feeling that she had no time to process and ask questions at her surgical follow-up appointment. Other dancers had experienced physicians being an hour behind schedule, feeling like they were competing with “a million other Obamacare patients”.
When interacting with insurance companies, several dancers had negative appraisals of their policies including that of being “overly complex and complicated” and “so damn expensive”. In a particular instance with customer service, Zoe struggled to obtain her insurance cards despite several phone calls and was thus prevented from booking a procedure she needed.
Positive experiences. Positive experiences were categorized into four types, relating to: referral/integrated care, dance, communication, and happiness with the service provided or clinician skill. Several of the American dancers, such as Zoe and
Sam, had a non-physician practitioner (for Zoe a chiropractor and for Sam a yoga instructor-bodyworker) who they valued and trusted with the management of their healthcare much like a primary care physician. Both expressed that over time, that person had gained their trust through “miracle-working” and Zoe commented “I really respect her, she has that holistic approach”. Both Zoe and Sam, and a handful of other dancers expressed that being referred was monumental to them; having connections with a local hospital or skilled practitioners, being “generous with those connections” (Fern), and making the referral process “not adversarial at all” (Ben) were positively regarded. 193
Positive experiences that were related to dance included: a clinician being an ex- dancer, a clinician changing their treatment to be more dance-specific, or a clinician expressing a willingness to become more educated about dance. Vivian had a physician attend one of her performances; after that experience Vivian reflected “we had a whole conversation about her understanding, I felt really lucky to have her”. A physical therapist working with Nora asked her to bring in tapes of her tap dancing as well as her shoes to learn more about the specific demands of tap dance. Fern was pleasantly surprised when an emergency room physician exclaimed that she had to be treated differently because she is a dancer. Quinn, who is a triple threat (dancer, actor, and singer) had a good experience with an anesthesiologist saying “I said that I am a singer so don’t be junking things down my throat, I didn’t feel like I had to fight to be heard”. The dancers who sought out dance-specific care to begin with shared feelings such as
“confident they can make a correct diagnosis” and “trust them to keep me on my feet”.
Jade expressed a certain inclination for clinicians who are ex-dancers comparing her experience at two different clinics “I didn’t get a sense the PTs there were dancers themselves…[at the other clinic] all of those people were dancers at some point and they sort of knew where I was coming from”.
Communication was also highly valued, as also discussed in the section below
Communication with healthcare professionals. Giving time, educating the dancer about their body and the pathology, expressing active listening, and asking in-depth questions all were valued qualities. Specifically, Zoe spoke at length about her appreciation for practitioners who asked more lifestyle questions (sleeping, eating, activity types) that acknowledged her active lifestyle. In conjunction with specific practitioners 194 communication skills, two dancers commented on the administration's interface; “feeling welcomed” and having an easy-to-navigate online interface were appreciated.
For some dancers, a clinician’s mere talent that had them raving. Speaking about a physical therapist, Quinn gushed “he is gifted from another source than himself like spiritually, he can tune into people, he is a healer”. Coral really appreciated her chiropractor calling her “the bomb, she rocks so much”. Vivian appreciated learning from her gynecologist saying “she taught me some home remedies and those were really effective”. Jade, who had experienced feeling of being forgotten in past physical therapy clinics noted that a certain physical therapist “would be seeing four or five patients at a time, jumping around, but I still felt that she was there for me when I needed her”.
Moreover, Jane discussed the benefit of having an open-clinic style of athletic training services available to her while in college “we could go when we needed anything, like hey my calves are tired today and we would be treated. It was maintenance-based athletic training”.
Communication with healthcare professionals. For the American dancers, communication with healthcare professionals included recalled conversations as well as reflections about bedside manner with physicians, physical therapists, massage therapists, athletic trainers, bodyworkers and so on. Many of the dancers expressed that they appreciated having the time of their physicians and equally wanted to be spoken to at
“their level” while not having their bodily awareness underestimated. In addition, several of the dancers noted the importance of having a clinician who is straightforward, or blunt, with their medical advice. The concept of being given enough time to hear a diagnosis or other new information and being allowed the time to sit with it and ask questions was set 195 as the ideal for the dancers; Quinn praised her physician noting: “he didn’t have extra time, but I had a [emotional] moment in his office and he let me have it”.
When asking questions and engaging in a dialogue with medical professionals, the dancers expressed that a physician’s ability to adjust their dialog to address the clinical understanding of the patient served as an indicator of clinical skill. Olivia said she is looking for a clinician she can “have a conversation with and [is] willing to engage with
[her] about what is happening in [her] own body”. Quinn felt that there is a “sweet spot” of language for physicians saying “they will break it down and not talk to me like a child, but in plain terms XYZ...because you might think it’s the end of the world but it’s just a long word. I wish they could find a way to split the difference”.
Sam offered an inverse frustration and gave an example of a clinician who appeared to not understand or recognize the acronym that Sam was using to identify an injury (it was unclear if the physician was surprised Sam brought it up or if they didn’t recognize the term). Sam expressed “when you can say to a doctor I injured my SCM and they respond with what does that stand for? Are you fucking kidding me? Why are we wasting our time here?”. Moreover, being able to engage in a conversation was important to Sam noting it made for “a much more interesting conversation when the provider wants to engage in conversation with you”. Vivian noted that in order to be her own advocate, she does her own research and comes prepared to have conversations with physicians. She said she typically knows what she wants saying:
I want a doctor who listens to me and if I go in and say I need physical therapy, I
get physical therapy as opposed to having to negotiate a visit with the podiatrist
first and then six to eight weeks of painkillers. 196
She noted that she has felt very comfortable communicating with her physician who is part of the LGBTQ+ community; Vivian explained “it’s a more progressive community and more holistic oriented...they actually hear you and take that into consideration”.
Speaking with a “straightforward” or “blunt” physician was also important to the dancers. Zoe had an especially poignant story about an interaction with a surgeon that she appreciated:
He took me to look at the MRI. [He said] I know you don’t really know what
you’re looking at, but this is the worst thing I’ve seen on a 35 year old, and if you
weren’t a professional athlete I would be sending you for a knee replacement...but
today I will aspirate your knee and give you a cortisone shot. Of course I don’t
recommend you to continue to have steroid shots but I know you have a
performance coming up. At that point he advised me about a surgery to clean up
the meniscal debris that could improve my movement quality.
Zoe explained how within this conversation he gave her options to choose, was straightforward with those options, and acknowledged that she was an athlete and thus had to keep performing. In contrast, Fern’s experience has been of physicians involved in her rehabilitation who struggled to tell her “don’t dance...it’s safe to dance...it’s okay to progress this way”; which has left her lacking clarity about what is safe and what is not.
Australian Dancers’ Reflections on Care
Reflections on Care discusses negative and positive experiences that dancers shared during the interviews. In the re-telling of the process of injury including the diagnosis, treatment, and rehabilitation, the dancers would often offer their own appraisal of the services, making clear what was favorable or not. Moreover, under the reflections 197 on care, communication with medical professionals was prominent therefore it is discussed separately speaking about themes of trust, understanding, and a space for listening.
Negative experiences. For the six Australian dancers who felt they had a negative experience directly with a physician or other medical professional, all of them noted feeling misunderstood as a dancer or that the medical professional didn’t emphasize or show effort in trying to understand the demands of their dancing. Piper, a freelance dancer, summarized the sentiment when she said:
I find it frustrating when practitioners go Oh, you’re a dancer, we understand
what you need, when actually their vision is of a ballet or company dancer who
have a particular physicality and facility that I don’t have...the conversation hasn’t
quite happened in a way that I feel the practitioner really understands what I am
and what I do.
Piper and Harper both expressed that even though they are able to see dance-minded physiotherapists who work for large dance companies, that they often feel misunderstood when they seek treatment as a freelance dancer. Living in a smaller city in Queensland,
Alynn expressed that she doesn’t have access to dance-minded practitioners and that
“haven't understood the specifics of what [she] needs as a dancer”.
Aside from being misunderstood as a dancer, Australian dancers retold stories of treatments and interactions with medical professionals that they felt were either poor in quality or caused damage. Emotionally, both Harper and Gwen had experiences where the interaction with a practitioner caused them to take offense or change practitioners for comfort. In her youth, Gwen interacted with a physician who in her words was “too- 198 blunt” and “pretty much placed me on a scale” when dealing with an eating disorder.
Harper, also in her youth, was instructed by a male physiotherapist to perform intravaginal manipulations on herself with the goal of gaining awareness of her pelvic floor; Harper said she didn’t try it and felt offended in the moment by the treatment option. Yasmin brought up that when she was having her appendix out and was “about to go under anesthesia” she attempted to confirm with the anesthesiologist understanding of a blood clotting condition she had, and the anesthesiologist didn’t know what her condition was. In Kat’s stories, twice she felt that she received poor treatment that caused negative effects on her health. In one situation, she had a foot fracture and by the first physician she sought care from, they misdiagnosed the fracture and didn’t refer or follow- up with her; she ended up seeing a massage therapist who correctly diagnosed it which allowed her to go back to her general practitioner and self-advocate to be referred for a bone scan. Kat had a tour in Europe soon after as she mentioned “I did keep dancing as it was getting better, but waiting definitely prolonged the healing”. Moreover, at the time of the interview, Kat was in the middle of managing a gastrointestinal issue that her physician feels is due to years of taking ibuprofen without food when dancing in pain.
Reflecting on her current condition, Kat noted that while she was at university the collective conscious was not “she's injured, she's taking these drugs, she needs to eat food”, it was “everyone had to be really skinny, so no one ate food at that point in time
[and] no one said to me, don't have painkillers on an empty stomach”. The lack of patient education was one of Kat’s most negative experiences with healthcare.
Positive experiences. Positive experiences were categorized into four types, relating to: dance, referral/integrated care, time and depth of conversation, and stories of 199 positive regard for past clinicians. For the Australian dancers, dance-knowledgeable clinicians were appreciated but less the norm. Ida felt positive about a physiotherapist who had “an incredible understanding of the fact that I wanted to be able to dance” similar to Harper who “value[s] people that believe I can get back [to dance]”. Liam appreciated his Pilates instructor who was an ex-dancer saying “he knows where I’m coming from”.
Gwen was the only Australian dancer that had an experience with a full medical team; at the time she was working through an eating disorder. Her team consisted of a psychologist, a physician, and a nutritionist who “all worked really well together...they were all very personable and seeing them regularly helped”, especially compared to the negative experience she had previously had with a single-operating physician. Without a medical team, individual dancers must reply on a referral system. Gwen mentioned that while employed at a large ballet company she “had a physio...the healthcare person for the company, she looked after everything whether that was mental health or injuries and then referred off to a specialist that she thought if necessary”. The majority the freelance
Australian dancers did not note having a practitioner that was well versed at referring besides Kat and Ida. Ida mentioned that her general practitioner “doesn’t pretend that she can be a psychologist but she makes sure I get the help I need”. Likewise, one of Kat’s most positive experiences was with a physician who, in Kat’s words: “referred me for a whole bunch of different scans, as well as seeing her in the interim”.
Speaking more of the same physician, Kat said “it’s the time they spend with you, how thorough they are with you and always...they spent 45-minutes with me just to hear everything that I had to say and everything that I was experiencing or feeling”. Time 200 spent was often connected to the depth of communication the Australian dancers perceived. Sometimes being comfortable in the depth of a conversation was related the dancer’s impression of a profession such as in Piper’s case:
I think so if I am communicating with a doctor, I think it is very much just talking
about what pain am I experiencing and what is causing the pain. [Versus] with an
osteopath, I feel like it can be a bit more ambiguous conversation, I think I am
feeling this, I am not really sure why.
Harper laid out that ideally she values clinicians who “listen, have faith in their own abilities, and have faith in my ability [to recover]”.
Many of the Australian dancers had found at least one practitioner in their career who they felt very positive about, had seen repeatedly, and thus referred their dancing peers to. The reasons were always unique to the dancer. For Alynn, she had two great experiences with massage therapists; she detailed one very holistic practitioner saying:
He kind of had that gift of, you tell him where you were at, how you’re feeling,
and he would rarely address them symptomatically but more directly. He would
really listen to your whole body and take it all in and say this tiny spot in your
ankle is affecting the tiny spot in your shoulder. He had an interesting sort of
holistic connection.
For Liam, he expressed appreciating his intellectually curious, skillful Pilates instructor detailing “he's always looking at studies, it's purely from the thirst of knowledge that I've been able to [become more educated]. Seeing him has allowed me to learn so much and it's great to be able to talk to an ex-dancer about the body”. Very impressive was Una’s thirty-five year relationship with her physician-osteopath who she called “a card carrying 201 genius, spot on with diagnosis and understands the whole pathology of the body”. For
Ida, it was about being empowered as a patient, speaking of a past psychologist “she never told me what I was feeling...she was gentle, kind, passionate, and seemed genuinely interested in my life”.
Communication with healthcare professionals. Three main ideas came of the
Australian dancers speaking about their past experiences with communicating with healthcare professionals: trust, understanding, and space for listening. These three elements were missed when absent and appreciated when demonstrated. Emerson and
Liam both spoke about needing a high level of trust with their company’s associated physiotherapist but for different reasons. Emerson expressed that within a physical assessment or within a rehabilitation program a dancer’s technique will be critiqued and possibly altered; Emerson finds his own technique to be very personal and possibly a
“fragile place” that he feels as though “someone is coaching you to drink your morning coffee”. On the other hand, Liam expressed a need for trust because, in his words: “my body is my tool, I can’t afford to have someone misusing my body”. He went on to say that he places a lot of trust in friends’ word-of-mouth recommendations, but still feels that no matter how skilled the clinician, there is a learning curve to working with a new body.
Understanding was an emphasized topic with three freelance dancers, Piper,
Alynn, and Harper each expressed that they’ve experienced feeling misunderstood by a physiotherapist. Harper expressed frustration with the assumption that dancers don’t have an “awareness or intelligent understanding of their body” which can be a root of miscommunication. Harper had a markedly poor experience when she sought care from a 202 physiotherapist associated with a large ballet company; she noted “what was very frustrating about this physio was her distaste for the fact that it had taken me so long [to seek care], I didn’t appreciate that as well as she couldn’t understand what I was doing” as a freelance dancer compared to a full-time ballet dancer. In agreement, Piper expressed that she often feels that practitioners have an idea of what a ballet dancer does, but struggles to understand other genres or a freelance career.
The final aspect of communication was the appreciated feelings dancers expressed when their practitioner made time and space to listen to them. This was in opposition to feelings of being misunderstood, when practitioners are perceived to carry assumptions of how their dancer patient moves. Yasmin described her ideal type of medical interaction stating:
I like it when people make you feel like it's safe to inquire and it's safe to ask
questions, you’re not going to sound silly and I also appreciate when they are just
a little bit more they have a laid-back vibe about them.
Similarly, spending time to arrive at a specific diagnosis was reflected on by Kat regarding her gastrointestinal issues: “she spent 45 minutes with me just to hear everything that I had to say and what I was experiencing or feeling. Then she talked me through the possibilities; very generous with her time thorough”.
Complementary and Alternative Medicine
Often speaking about an ideal of holistic medical practice, many dancers from both countries described practitioners that were not physicians, physical therapists / physiotherapists, athletic trainers, nor nurses as “alternative” practitioners. Moreover, having a holistic approach meant widening the diagnostic and treatment focus to include 203 factors such as interdependent joints in the body, the dancer’s lifestyle, the emotional- cognitive-physical connection, and mental illness. The next two sections exploring the
American and Australian dancer’s words make use of the same verbiage, however recognize that in many instances holistic means Alternative Medicine or Complementary
Medicine (CAM) or Integrated Care.
American Dancers and CAM. The majority of the American dancer interviewees commented on a form of healthcare which had positively added to their overall health and wellbeing that they considered either alternative, complementary, or integrated. Many dancers expressed an appreciation for “holistic healthcare” which was typically not defined by the dancers, but contextualized with words such as “listening”,
“Eastern”, “feminist”, and “natural”. Zoe went into detail noting that when imagining an optimal healthcare environment she said “holistic care: I want doctors that are willing to look at the whole picture, the physical, mental, emotional, spiritual health”. Zoe went on to speak about the qualities of her primary care physician she appreciated: “I have a very good relationship with my primary care doctor, I really respect her as a physician, she has a holistic approach”. Moreover, Coral and Olivia each stated that a non-primary care physician (a chiropractor and a massage therapist, respectively) are their main providers that seek care from on a regular basis.
Other dancer definitions of holistic care were less direct. For Vivian it was a primary physician who also practiced integrated care: “I love the fact that she does acupuncture in her office...I think it’s great that she is participating in alternative healthcare - it’s pretty rare and lucky”. For the other dancers, speaking about complementary and alternative practices was in relation to more conventional medical 204 practices. Coral who dotes upon her chiropractor saying “my chiropractor knows my life completely” went on to say she felt that her chiropractor “value[s] my overall health and wellness more than the other general practitioners I have seen...they don’t ask questions that seem to be really significant, they just want to give you medicine to fix the problem”.
Coral continued by relaying her experience of a severe fall during dancing:
Medical doctors were telling me I was never going to walk and run normally
again; They were telling me I had to stop dancing…then my chiropractor had me
back up and running in eight months, an eternity in a dancer’s career.
Fern perceives an issue with practitioners who “don’t want to find the root of the problem” whereas in her experience with acupuncturists and massage therapists notes their “whole belief system is finding the root of the issue to solve that and to progress the human being as a whole mind-body, collaborative creature”. Finally, Sam made note that it is “easier to find a bodyworker like a massage therapist who’s able to help you than a physiotherapist…I think it’s something about the listening part”. Communication - being heard and being given time to speak and ask questions - was central to the examples the dancers gave of why they preferred holistic and alternative practitioners.
The reasons that dancers sought out care or took Somatic practice classes (such as yoga and Pilates) ranged from self-care and preventative medicine to injury management.
Sam stated that he does “a lot of yoga” and finds that without treating the mental and emotional component [of physical injuries] healing takes longer. Fern noted that from the
Alexander Technique she gained a “new clarity” to her body and moreover found it touched her on a psychological, emotional, and physical level, “it felt that there was an incredible clarity and knowledge of my body…it helped me cope with [my] injury…I 205 learned how to work with it, but it did not necessarily heal it”. In a more general health aspect, Vivian noted that her gynecologist “actually had home remedies and other ideas and [a] kind of alternative approach - I think mainstream medicine doesn’t do it for everybody”.
A common thread that prevailed from the American dancers was the issue that massage is not covered by insurance; more broadly, many alternative practices - with the exception of Vivian’s acupuncturist / medical doctor - were not covered by insurance plans and are therefore often paid for out-of-pocket if afforded. Zoe noted she responded well to a manual technique called Rolfing, however it is “very expensive…maybe $1000 for eight to ten sessions, you’d have to have the whole series but it’s not covered” she went on to say “I can’t afford bodywork on my budget, I wish I could and I wish it was covered in my health insurance”. Vivian was aware of her luck in having acupuncture covered because her physician performed it but additionally noted “I have been relying on massage therapy that’s not covered throughout my whole career…joking with my students that [my massage therapist] keeps me vertical”. Additional praise for massage came from Olivia “if I could afford [it], I would go to a massage every month, which I did for a while [be]cause he helped so much [when] I went”. Vivian supposes that in the near future, more physicians will offer more alternative practices due to demand and that will open the gateway to alternative practices being covered by more insurance companies.
Australian Dancers and CAM. Half of the Australian dancers mentioned alternative practitioners they had seen and therapies such as massage and acupuncture.
For those who did, all commented on how those practices and therapies positively added 206 to either their dance practice, bodily awareness, or performance. Alynn spoke about Yoga and Feldenkrais method; for yoga she proclaimed “yoga has been an incredible healer for injuries….a real sort of stabilizer for injuries and a way of finding balance in the body”.
Whereas for Feldenkrais she noted “also a big assist…it’s amazing at fine tuning mind- body awareness and understanding injury”. Liam works with a large company who provides 30 minutes of massage to their dancers, he states “it’s purely for maintenance purposes and is great for even half an hour just to loosen our bodies up”. Yasmin and
Harper both enjoyed practicing Yoga and Pilates noting that they “do it for enjoyment” and that it’s “good for the body”. Few of the Australian dancers used an alternative practice or technique for healing from injuries.
The experiences of partaking in a Somatic practice like Pilates or seeking care from a practitioner one-on-one seemed to be personal preference. Alynn noted that her massage therapist is “quirky” because she will speak to Alynn’s muscles when she is working with them. Alynn felt that “it’s kind of funny, but with the mind-body connection…hearing her voice and feeling her touch….is a positive influence on how she appraises the treatment”. Harper spoke in some detail about her time working with the
Feldenkrais method specifically how it relates closely to how she moves and that “it slows you down and makes you notice particular pathways...it is about ease and efficiency”. On a similar note, Ida remarked how related her Pilates and dance training are: “when you do reformer work, it is so much fun, you can really feel like you are jumping and doing arabesques...it has the ability to make you feel like you are on the dance floor”. 207
In terms of cost, three Australian dancers drew attention to the affordability of these alternative treatments and their own thrift in working around costs. Liam said that if he needs more than the allotted 30 minutes of massage per week for his own body maintenance, it comes from his own pocket. Yasmin, who enjoys Pilates for exercise and enjoyment, can often manage to get into classes for free because some of her dance classes take place in proximity to a Pilates studio. Finally, Harper also demonstrated some thrift when she described purchasing all of the props for restorative yoga so that she can practice in her own home without the per class cost. This also affords her flexibility in the time she can practice.
Managing Mental Health
Five of the American dancers spoke about working through either current or prior depression or anxiety and one reported of a past eating disorder. None of the five dancers reported currently having a mental health professional that they regularly see. Zoe and
Olivia noted that they go through a physician for prescription antidepressant medication; in Zoe’s words “I have gone to a counselor in the past, but I am not seeing one now. I have taken antidepressants and I have found some that worked and stayed on them for a period of time, but I have actually found that it is just as effective for me to deal with that through my primary care doctor”. Zoe noted that the out-of-pocket costs or unfamiliarity with what her insurance policy covers has been a barrier to seeking treatment or counseling from a mental health professional. In a similar vein, Benjamin finds that
“jumping through hoops” to get a first appointment was daunting and in his case, he ended up not having a good experience with that therapist; “it was just not a good fit” he said. 208
Fern reflected on her impression of mental health professionals from the time she was in high school saying she “heard terrible stories about going to therapists and it definitely left a bad impression”. Currently, Fern noted she is working through several injures that she feels are related to her anxiety and depression noting “a lack of clarity in the mind and a lack of clarity in the movement”. Moreover, she noted that her attitudes about mental health professionals are changing, saying “I’ve gained a lot of information from people who have had wonderful experience with mental health professionals so finding professional help is only a recent thing... now I am on the hunt”. For Olivia, she noted the stress of living in New York City runs her down mentally when she said “it's scary not to know what you are going to be doing next month and I think that...it's a very mentally hard city especially if you didn't grow up here”. When Olivia made the move to
New York she had left a full time company in upstate New York to pursue freelancing she described the change and move as ‘terrifying’ and that it was like ‘falling into the unknown’.
Several of the Australian dancers commented on their experiences accessing and interacting with a mental health professional. Emerson’s company offers him access to a sports psychologist and three sessions included with his contract. He compared finding a psychologist to finding a soulmate. Reflecting on the psychologist he saw through his company, Emerson said apathetically “I might as well because I don’t have the time to find anyone else”. Similar to the American dancer Fern, he noted when that when he was younger he had a fear of seeing a psychologist saying “that is just a human fear, not a dancer's specific fear, everyone's scared of going to the psychologist”. 209
During Gwen’s younger teenage years, she was training in ballet and had “a little bit of an eating disorder around ballet”. She told of being brought to a general practitioner by her parents for evaluation and treatment and having had a terrible experience. “He would only talk to Mum, not directly to me” she noted and “he had a very strong view and basically put me on the scale and referred me to a hospital”. She said after that she left the hospital screaming and noted “that's the most negative experience that I have had…because of his bluntness and he didn't ask any questions about how I was or try to delve further into the situation”. Fortunately for Gwen, her parents arranged for her to see a group of specialists: a psychologist, a doctor, and then a nutritionist, who Gwen recalled worked really well together to assist her. From counseling in his teenage years,
Liam noted he gained a better sense of independence after learning strategies to cope with his depression and moreover, a greater sense of a personal philosophy. Ida also described seeking out a mental health professional during a time when she had depression and an eating disorder, she reflected: “I didn't really understand why I couldn't get out of bed, why I couldn't stop crying; but she helped me to pull the threads apart and see where they went and to understand myself better”. Yasmin’s experiences with mental health were unique to a boat accident in her youth which placed her in early therapy to work through trauma. She explained that her relationship to therapy is maintenance based: “every couple of years I feel like I need to check in and get some tools on how to manage anxiety or mood swings”. Moreover, she said her current therapist taught her the benefits of exercise and meditation which she has brought into her daily self-care regimen.
Harper, Kat, and Ida all attended the same performing arts academy to study dance for their Bachelor of Arts degree. In Harper’s university training, she painted a 210 picture of lacking any mental health or holistic support for dance students. During this time, she was working through learning about her unique motor learning style and the residual anxiety from that process; she reflected “the idea of mental healthcare was not spoken about, it was implicit that we were all competing, that [our reality is] going to be hard”. Moreover, Harper and Kat said that only the “extreme cases” or “massive obvious issues” were referred to a sports psychologist by the teachers at her school. Kat noted
“anxiety, depression, and eating disorders were going around...but it was just part of the gig”. Ida attended the same university and noted that herself and others in her group were living with eating disorders that were left unaddressed by the institution. Moreover, Ida was dealing with depression while training and said “one teacher made an effort to ask how I was, I had visible cuts on my wrists, I was quite clear about not being okay...I don’t feel like there was much support at all”. In Ida’s story, she had depression, anxiety, and an eating disorder which all coincided during her time in university; she ultimately decided to take a year off during which she worked with a psychologist from her hometown about her depression and managed her eating disorder at a later time.
Receiving Dance Specific Care
Dance medicine and science is loosely defined by the actions and research interests of medical professionals and somatic practitioners. For the dancers, dance medicine can be a clinician who identifies as ‘dance-specific’ (a title that dancers grant when they find a practitioner who is empathetic to dance or ‘dance-knowledgeable’. It typically means that the medical professional demonstrates a knowledge of the various demands of dance and caters their treatment to return the patient to dance or to manage them in a dance-minded way. The following sections demonstrate the thoughts, feelings, 211 and experiences that dancers had about the topic of dance specific practitioners and clinicians.
American dance-specific care. Fern stated that dance medicine and science feels hard to define because it is still developing and evolving; it’s something “that is supposed to take care of you but doesn’t always know how”. She expressed appreciation for having always danced in “dance medicine hubs” such as Boston and New York. Sam, a full-time contemporary dancer in New York, mentioned that he typically travels down to New
York for a “more specific health network for athletes and dancers”. As all the American dancer interviews were done either in or within a drivable distance to these hubs, the majority of dancers mentioned accessing these dance medicine hubs.
Even living in a hub, dancers noted that it can take time and resources to find a valued dance-specific or a dance-knowledgeable practitioner; a majority of the dancers expressed that it is common to build a network of practitioners through the references of other dancers. Comparing a dance-specific therapist experience with a non-dance specific one, Benjamin found that the dance-specific clinicians employed more active stretching with a Pilates reformer and assigned home exercise programs that included dance terminology and movements. Coral appreciated her chiropractor because, prior to an injury, they had been a dancer. “She understands a dancer’s body differently from others,
I have seen some other chiropractors that had different methods than she did, but she was just the perfect fit for my body”. Zoe also sees an ex-dancer for physical therapy when she is home in Rhode Island and Quinn enjoys a network of Broadway specific physical therapists who are associated with the big shows. 212
Both Sam and Zoe expressed that their biggest praise for dance-specific clinicians is the acceptance that they, the dancer-patient, will not stop dancing. Reflecting on a mole removal in her past, Zoe stated:
People who understand dancers know that we are not going to stop
dancing...that’s not happening, I am going to start moving and I don’t care if it
makes the scar bigger, it’s not like I’m going to cancel classes and rehearsal
because of it...maybe if the PT didn’t understand the life of a professional dancer
she would be advising me not to be dancing, she is not going to do that, she is
going to figure out how to keep me on my feet.
Sam noted that in addition to an understanding that he would continue to dance, he appreciated the “broad look at the body” in reference to how dance specialists tend to examine the interconnectivity of the body rather than focusing on a single joint during evaluations; he called that kind of tunnel-vision treatment “a band-aid”.
A majority of the American dancers had danced in or were living in Boston; locally there is a dance medicine department with several physicians and surgeons renowned for their work with dancers. Zoe had a neutral yet extensive experience when she told the story of “making a big effort that didn’t pay off” in regard to a soft tissue injury she sought treatment for. Ultimately her insurance was rejected and she ended up
“paying through the nose”. Jade, Fern, and Olivia each expressed disappointment in their care from the Boston clinic. Fern stated:
It never feels quite full-pictured”, she continued with a mocking tone: “we are
busy, you can keep paying us and we will keep giving you twenty-minutes here
and ten minutes there and making you come in for the MRIs and x-rays. 213
This was in reference to her muscular injuries that spanned years with various diagnoses.
Jade recalled the experience she had when trying to obtain an appointment at the clinic:
I don't recall what they said exactly, but they said Oh we can't see you, we need a
recommendation, I said, I don't have anybody. I fought every day to get in there
and I guess they were tired of hearing from me because they saw me free of
charge; I still don't know how I wrangled that, I was just fiercely advocating for
myself.
Jade compared this experience with obtaining an appointment at a different renowned dance clinic in another city, having stated “I just felt that the people at [that clinic] were much more understanding of what I was going through...I felt welcome there, even though I had to wait six weeks, they accepted me right away”. She does state that the quality of care was equal saying “they both [knew] what they were doing”. Finally,
Olivia, a ballet-rooted but genre-adaptable dancer, expressed disappointment with a similar experience speaking of a physician at the clinic remarking “I’m sure he’s been to the ballet, but that doesn’t mean he understands what I do”.
A perceived difference between dance-knowledgeable clinicians and non-dance- knowledgeable clinicians was often a lack of curiosity and question asking. Ben felt that his primary care physician of many years has not expressed curiosity about Ben’s activity in dance. Moreover, Coral felt that the medical professionals in her past had not taken her physicality into consideration, she went on to say “being a dancer means a different pain tolerance, different intuneness, and more active…too often [I] don’t get asked whether or not I am active”. Olivia had a diagnosed Os Trigonum injury at the age of 13, but her non-dance-specific physician did not predict that would cause issues in her career later 214 on; “they didn’t know it would be a problem in the long run”. On an opposing note,
Olivia had a great experience with a surgeon who was associated with the National
Football League, saying he provided her with a list of rehabilitation clinical milestones and exercises that proved to be very helpful as she “was in charge of [her] rehabilitation”.
Fern sustained a fifth metatarsal injury when she was hiking in the woods during employment at a summer camp in the Pacific Northwest; she expressed to me she was worried that as she was outside of the “dance medicine hub” of Boston and New York, the medical professionals she saw wouldn’t know how to approach her healthcare as a dancer. However, she stated “they said we obviously need to treat you differently because you are a dancer and I was like WHAT! You know this?”. She was pleasantly surprised to be treated well and expressed that the original fear she had was a shared emotion with her peers.
Australian dance-specific care. In Brisbane, Gwen found dance medicine to be a growing field saying that “care for dancers and athletes in general is becoming more important and prioritized, I know quite a few physiotherapists who are dance-related as well as working with the companies or with dance schools, I think it is becoming better all the time”. Kat found the difference between a dance-specific clinician and a non- dance-specific clinician to be their ability to have an anatomical conversation with the dancer-patient that includes common dance terms as well; “it’s about the language...speaking on my level” she said. A theme throughout the Australian interviews was finding a dance specific clinician through word-of-mouth recommendations of dancing peers. Una told a story of her first experience with a dance-specific clinician, 215 who she had seen nearly exclusively for 35 years, from the time she injured her back shortly after returning to Australia from Holland:
My father took me to an orthopedic surgeon and they were ready to get the knife
out to do an operation. [A friend of a friend] put me onto this other fella who is an
osteopath who said No, that's a bad idea and he got me better and has always
looked after me since; he looks after modern dancers and I have recommended
him and he gets recommended and recommended and so on.
This particular person was an osteopath and physician who impressed Una through his own journey rehabilitating himself after a motorcycle accident and being very physically fit at the age of 70 to the point he now trains Australian special forces.
Being a full-time ballet dancer, Liam enjoys recurring massage therapists and in- house physiotherapy which are both dance-specific and available during rehearsals, performances, and touring seasons. Una mirrored this sentiment reflecting on her time dancing for a major company in Holland. Even as dance medicine has grown in Australia,
Piper, a freelance dancer, stated that many of the known dance-specific clinicians are employed by the major ballet and contemporary companies and “are a little bit of a closed circuit”. In her experiences seeking care, she’s been left feeling frustrated because of her irregular freelance dancer lifestyle, and the time between jobs she noted:
I work on lots of different things and have big gaps [compared] to a company
dancer who is training every day and doing the same training. Sometimes I find it
very frustrating when people say Oh you are a dancer, we understand what you
need and actually their vision is for a ballet dancer or a company dancer that you
know have [a] particular physicality and facility that I don’t necessarily have. 216
Harper mirrored the sentiment in saying that she too has worked with a company- affiliated physiotherapist in Sydney who she felt was not flexible to her needs as an independent dancer; she reflected on the experience: “I would come in and not train everyday but still consider myself to be a dancer...she couldn’t quite understand [that] and there was a bit of judgement I felt in her demeanor”. Liam, a company dancer reflected a similar sentiment of being misunderstood by non-dance psychologists saying
“normally when I talk ballet to someone, they see what they think ballet is and maybe a caricature of it”. These stories highlight the gap between being a dance outsider and a dance insider in terms of dance milieu and expectations.
Knowledge of Body
Knowledge of the body encompasses knowledge of anatomy, biomechanics, pathomechanics, injury prevention, and injury rehabilitation. Dancers learn about these things through formal education within dance school, self-teaching, and from healthcare professionals when they sought care for an injury. A majority of the dancers expressed that having a good sense of anatomy and what is happening with their bodies improves communication and care with physicians and other healthcare professionals.
American dancer knowledge. The majority of the American dancers spoke about their body from a place of knowing or not knowing. For example, Sam noted that as a first year professional dancer he would “just take Advil and kept going and maybe get a massage”. He didn’t know how to take care of himself saying he “wasn’t taking care of himself in a way that he now understands how to”. This was a pattern with several of the American dancers, expressing an ignorance or naivety when they were beginning 217 their professional dance careers about their own anatomy and ability to recognize and treat injuries.
At the time of the interview, most of the American dancers recognized their current ability to know and recognize injury such as “knowing warning signs”, recognizing the interdependence of the body, and acknowledging their own pain tolerance and how that may affect their help-seeking threshold. This led to a better communication with medical professionals and thus, the treatment they received.
The process of coming into a place of knowing can be further divided into the following subcategories: learning in a formal setting or through personal curiosity, learning from an injury experience, and learning upon age and reflection of experience.
For the American dancers, very few verbalized any formal training they had in anatomy, injury prevention, treatment, or nutrition. One American dancer earned a Master’s of
Science degree in Exercise Science and she noted that she did learn about the injuries that dancers typically sustain, but not how to manage them. Furthermore, only Sam noted that he had any formal anatomy training during his education a contrast to Jade who specifically noted that she did not receive any nutrition or anatomy instruction during her education.
Learning from injury was the most common way dancers expressed a knowledge of their own body and anatomy. Said poetically, the freelance dancer Jade noted that the process of becoming injured and learning from it was just like polishing an old cup or table, it being the way to create the person and artist she was meant to be. On a similar thread, Fern expressed that her injuries have shaped the artist she has become saying “I have strained and pulled muscles before and those have kind of led me down a very 218 interesting place of learning about my body”. Fern expressed that is was from working within the limitations of her injuries that led her to discover how the improvisation technique allowed her to feel like a dancer in her own right. Sam, who was employed within a single company for seven years at the time of our interview, noted that “with
[his] neck injury, [he] has a responsibility as a professional dancer to know more about
[his] own body” remedying that fact by doing his own readings on anatomy as a home study.
Some dancers noted that at a certain age, they decided they needed to take a more proactive approach to their body through management, meaning they had to spend time learning how to manage their injuries; Vivian stated “it was a lot about managing what happens as opposed to expecting it to resolve”. In the same vein, Coral spoke about the shift that happened as she transitioned to be a dance teacher:
There is a huge shift in what the focus was, it was no longer about pushing
through the pain, it was about examining the pain, where it’s coming from and
how can I fix it and still continue to be a mover.
Experiences such as teaching and delivery of a child were also expressed to be points of learning. Quinn, a Broadway dancer who came to dance as a teenager (“late” in her words), expressed that because her facility was so well-suited to dance with abundant flexibility, it wasn’t until she began teaching that she went through an experiential learning experience of the muscles needed to obtain a certain position. She said “I thought I was controlling it, but that’s not what [was happening]”. She would “throw” her limbs into position because she could, not because she had the strength. On a different thread, Zoe, a mother of two, expressed that having gone through natural childbirth twice, 219 she found an “incredible sense of what the body is capable of doing…[which] serves as fuel for the physical challenges ahead”.
Australian dancer knowledge. When speaking of learning about their own anatomy, biomechanics, and personal body quirks, the Australian dancers offered a range of methods that have influenced their own way of knowing. About half of the Australian dancers noted they had some form of formal anatomy and wellbeing lessons during their dance training, either in university or at training schools. The range of take-away information from these lectures was wide; Emerson stated “I studied anatomy in Paris and London, but I barely remember the nomenclature of the naming system. I remember the look of things” to Yasmin noting that while she was a trainee, a physiotherapist would guest lecture about proper technique, injury prevention, and nutrition but Yasmin additionally learned more specific details from her ballet teacher who would drive her home each night after rehearsal. Harper expressed that while at university, her course was set up so she received six months of training in Feldenkrais technique and six months of learning Pilates. She and her peers could “pick and choose what to keep” for their own knowledge of anatomy and injury prevention. Piper meanwhile reflected that she had a course in “Kinesthetics” where she learned about “healing through awareness” but lacked the “here is what you do to deal with injury”. Una, a retired dancer who had danced professionally both abroad and in Australia noted she had very limited formal training; “I probably knew what a hamstring was, a knee, and a foot”, she went on to say “there was a little bit more [education] at her ballet school whereas Ida noted that she learned only about the musculoskeletal system, and felt that her training left out digestive, heart, lung 220 systems and topics of menstruation that she felt would have been important in her development.
Somewhat overlapping, several dancers tied in their own desire to learn, with a lack of, or less than complete, formal education which led them to seek out additional knowledge from healthcare professionals and somatic practitioners. For example,
Emerson who noted he had forgotten much of his earlier anatomy nomenclature, said he
“gets to analyze his technique with the [ballet] coaches and see what [his] habits are and how, as a dancer, [he] finds ways of cheating” which he then connected to potentially leading to injury. Ida had a unique situation where her anatomy teacher was also her school’s physiotherapist; this led to Ida noting “if you were seeing her for a physio situation, she would try and tie that into what she was currently teaching you in the class”. Liam positioned himself to be calculated about his methods for learning about the body saying it’s “purely from the thirst of knowledge that I’ve been able to get information which has allowed me to learn so much”, his teacher being an ex-dancer
Pilates instructor that Liam places much trust in. Liam went on to say:
I did a lot of self-taught work, because it was my body, the way I did it. But I
would consult with physiotherapists, doctors, osteopaths, masseurs…anyone that
had knowledge of the body, I would try and gain as much knowledge because the
more you know, the more you can use.
Other dancers noted that their knowledge developed from their own experiences.
Una said that for her “it was a case of having to listen to my own body…figure out what felt safe and how to do it…I did a lot of figuring out myself”. Similarly, Alynn noted “it is important to sit with yourself and just listen to your own body and figure out what it is 221 that you need, because it can be really convoluted and consumed by other people’s suggestions and opinions”. Gwen, currently a ballet teacher, began by telling me she was always interested in anatomy and biomechanics, noting that as a dancer she “figured all that out for myself and for my body as well”; but once she was injured (with a surgical case of bilateral jumper's knee), she reflected that going through the process of injury further fueled her interest in learning about the body which supports her teaching career currently. Expressing more of a reflective tone, Kat said:
As I’ve gotten older, my understanding of the body [has grown] with my training
and essentially, because I’m more aware of the [things that caused pain the
past]…it’s only at this age now that I am thinking Oh my God, I could have got so
much more out of myself if I had known what it needed or gave it what it needed
as well.
As a group, the Australian dancers did not speak of what they learned from specific injuries over their career - but moreover, their communication and relationship with medical practitioners and how this was a resource for them. Emerson noted:
Every time I would have a niggle (pain) or a little injury, I would ask a physio to
explain to me in detail what was involved…I can feel a lot of things, but I need to
have some theory behind it.
Slightly more at odds, Ida described that her osteopath has introduced her to a new perspective saying they:
Are coming from a different perspective and was encouraging me to not see it in
such an analytical way, because I was relating it to something strenuous and
physical where he was saying it was much more of a sustained, chronic thing. 222
Finally, Liam who presented as an optimist, said “I actually used [being injured] to my advantage to learn about how I can prevent that in the future, how I can strengthen that area so that it is better than before, and basically use it to develop me not only as a knowledge dancer but also to strengthen myself and that’s been one of the best things about being injured, that I can use it to my advantage as opposed to just thinking this is the worst thing”.
Several times during the interview the dancers would, in their own ways, demonstrate a knowledge of their body that had come from any of the previous means mentioned. Emerson noted that “his body loves routine and consistency” and that change in this resulted in “things going a bit wrong”. Alynn was aware that she and her dancing peers have a higher pain tolerance and moreover, that this may delay seeking medical treatment. Kat, who at the time of our interview was recovering from a long gastrointestinal issue, demonstrated heightened awareness of gut bacteria which she had picked up from her contact with medical professionals but also through personal reading on the subject. Finally, Una who has had a long career both as a professional dancer and as a dance teacher was very tuned into what body types would be well suited (which I took to mean not prone to injury as easily) to ballet versus modern versus other forms.
Her awareness that her own body was “straight up and down and pretty strong” made her well suited for dance from a young age.
Comparative Results
The third research question asks that the data be compared between countries for unique qualities and similarities.
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Unique qualities. From the twenty dancers’ stories collected, differences between country of residence were analyzed. Differences based on country of residence are described by access, cost, and quality of healthcare.
The ability to access healthcare for Australian freelance dancers was reported as adequate when speaking about general healthcare services; however, in terms of finding dance-specific care, the majority of freelance dancers reported difficulty in either finding a dance-specific clinician or finding a dance-specific clinician who was flexible enough to work both for a ballet company while understanding the workload of freelance dance artists. The opposite was true for American dancers, based on where the interview locations were centered (Boston and New York), particular renowned dance clinics existed, which most dancers mentioned seeking care from; however, for American freelance dancers, affording the ability to see a physician or dentist was stunted by employment status or income. Moreover specific to the American dancers, being married or under the age of twenty-six (or twenty-nine for Coral) allowed them to remain on health insurance and therefore afford access to healthcare providers or mental health professionals. Several other unique factors to the Australian dancers interviews were: isolated location in Darwin for Ida, the inability to purchase private health cover quickly for Kat, as well as all 10 Australian dancers who indicated that a physiotherapist was the first type of clinician they sought care from for a dance injury. Compare that to the doctors, physical therapists, and alternative practitioners that the American dancers reported seeking care from first. A large and final difference between the American and
Australian dancers regarding their access was that the Australian dancers reported grappling with the choice between being on private cover or using the public healthcare 224 system. Every American dancer by contrast reported wanting to afford health insurance or gratitude that they had health insurance.
The cost of healthcare or health insurance was another difference analyzed between the dancers’ stories. The Australian dancers rarely mentioned the expense of affording private health cover as an issue whereas they did discuss several means of being thrifty and budgeting their money to afford non-covered services such as massage as a form of maintenance. American dancers expressed that they either were not confident in their ability to afford health insurance or that without sliding-scales or an insured partner that they would be without health insurance. A few American dancers reported going without health insurance for substantial amounts of time due to cost prohibition. Finally, in assessing the general tone of satisfaction and quality, there were limited patterns within each country. For Americans, it was often reported that physicians did not spend enough time with them either during a diagnosis process, for a consultation, or during a post-surgical follow-up. For Australians, this element was not discussed as much as a freelance dancer’s struggle to be understood as a freelance dance artist.
Similarities. The American dancers’ and the Australian dancers’ stories surrounding quality of care were similar. Themes of access and cost were also shared; companied dancers in both countries expressed greater affordability and access to healthcare than freelance dancers. One practice that all dancers shared was that they continued to dance when injured or in pain. This was reported both in the survey data as well as in the interviews.
Several aspects of quality of care were shared by the majority of dancers. Many of the dancers expressed that they expected or wanted to learn from their interactions with 225 healthcare and mental health professionals. Dancers in both countries expressed an appreciation for, or a sense of lacking when without, a holistic experience when with a clinician. Both groups shared an array of positive and negative experiences with particular clinicians and all dancers rated having a “good relationship with provider” as the least (N = 19), or second to least (N = 2), important aspect of treatment. Conversely, the majority of dancers in both countries cited a specific person that they had an excellent patient-clinician relationship with who they typically admired greatly and often would prioritize seeking advice or treatment from.
Commentary on cost was not often a shared narrative between the countries, however both groups did cite a wanting for more complementary and alternative practices to be covered treatments under their health insurance policies. Many of the dancers felt that alternative care practitioners were better active listeners and more responsive. In terms of access, differences based on companied status versus a freelance status were similar between both countries. For Sam, Liam, Emerson, Ida, and Alynn, being companied offered them employer supported private health insurance (health cover).
Moreover, specifically addressing the dancers in a large ballet company, Liam and
Emerson, had access to in-house physiotherapy, weekly massage, and healthcare support when on tour.
Dancers and Pregnancy
This section addresses the final research question of the project; what are the experiences of healthcare for dancers who have lived through a transition such as pregnancy? Four dancers, two American (Nora and Zoe) and two Australian (Piper and
Una), had already experienced birth; while Piper was pregnant with her first child at the 226 time of the interview. One American dancer-mother did not begin dancing professionally until she was 41, so she will be excluded from this section. Three of the four mothers performed while pregnant and Una taught dance through her pregnancy.
In 1987, Una was a companied dancer in Holland when she retired from professional dance to start a family. Una noted “it was just what you had to do, [the company] wasn’t going to employ someone who was pregnant” and moreover she noted the company’s message was “we’re not going to hold a job for you, we have a company to run”; she went on to say that “these days it’s different”. Una continued to teach dance through 38-weeks of her first pregnancy, but with her second pregnancy (twins) she stopped considerably earlier in her before that with her second birth of twins noting that the students made comments such as “your children are going to be dizzy”. Today, Una works for two major dance companies in Sydney and has seen many female dancers return to their company positions in the company after their pregnancy in approximately four months after giving birth. Una spent a good portion of time making the case that mothers return to who come back to dance are better artists than when they left having describing the dancers as said the dancers she sees are “often stronger, not just physically, but also mentally and emotionally. I have seen them before and am looking at them afterwards and thinking, this is a not only a better artist but a stronger body”.
Zoe is a mother of two and a co-owner-dancer of a contemporary dance company.
She carried her first child as a senior in college, at the age of 21, while taking many dance classes. She relied on midwives for both of her pregnancies and births and while commenting on the physicality of dance said she did “a lot of reading and knew what was and wasn’t safe”. She danced throughout her entire pregnancy with her first child but, 227 like Una, did not do so with her second. She commented that she was able to remain very active with yoga and other physical activity. Zoe’s midwife joked calling natural childbirth “testing the equipment” and more seriously commented that by “experienc[ing] natural childbirth, you will have an incredible sense of what your body is capable of doing which is great fuel for the physical challenges of parenting”. Zoe communicated that her corporal awareness as a dancer served her well during the process of preparing for the birth and moreover, her college dance instructors were very supportive and trusting of Zoe setting her own physical limits in class. Zoe reflected “I’m a mover and was compelled to keep dancing”.
Piper was six months pregnant when we spoke; she had decided to stop dancing a few weeks prior. Her decision was influenced by her recent experiences on a project: as a dancer and collaborative-choreographer in her most recent project she felt that the mental clarity she relied on to create work was hindered by an interruption in her usual familiarity with her body. Specifically Piper said creativity is “not just an intellectual act, feeling this restriction in my body, this total world of unknown, had me feeling restricted in my creative thinking. It became just a little bit frustrating so I felt like that’s enough of that”.
In terms of medical care, Piper expressed another frustration in the advice her obstetrician gave her. She felt that the advice she was getting was not fully informed and showed a lack of understanding about the specific dance pieces she was engaging with.
Piper noted “I felt like ‘do you understand to what extent I am using this part of my body?’ That felt a little frustrating to not feel 100 percent confident [in] the feedback”.
Moreover, upon reflection of the medical advice she received, Piper said “I wanted 228 something more specific, in the early stages of pregnancy, I was much more worried about miscarriage and doing something wrong that will hurt the baby”. Piper remarked that there was a lack of resources available for pregnant woman that discussed specific limitations of participating in physical activity. Piper faced experienced further frustration in a child birthing class, she remarked they “spent fully five minutes on the pelvic floor, that’s one part of my body I’m very familiar with!”.
Only Zoe mentioned affording the process of pregnancy and delivery. Her mother’s insurance policy covered Zoe during her first pregnancy and birth while her husband’s insurance covered her for the second. Not a mother at the time of interview,
Olivia noted that she was conscious about saving money and transitioning to teaching in order to earn more money as she often thinks about having children of her own. Piper did not mention the cost of her pregnancy but did mention that having a child was encouraging her to think more about purchasing private health cover as she had spent her entire life without private health insurance. Moreover, Piper had plans to keep working after maternity leave through a woman/mother-owned dance company that she felt would be very supportive of her new-mother status.
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Chapter Six: Discussion and Implications
Introduction
This chapter presents an overview of the completed study and synthesis of the major findings. This work examined dancers’ stories of how they’ve interacted with healthcare. In another light, this is a commentary of the lived experiences of citizens, of a certain profession, functioning within two nation’s opposing healthcare systems. The organization of this chapter is such that both perspectives are explored by ranging from a wider national healthcare policy lens that narrows towards the individual experiences and the dancer-specific elements. Within these perspectives, the themes from the previous chapter are discussed and placed in context of previous literature. This is followed by exploring the implications, both general and for healthcare professionals, discussing the limitations to this research as well as future directions for researchers.
Overview of the Study
This study was the first to use qualitative interview methods to examine the lived experiences of dancers accessing and interacting with healthcare throughout their career in two countries, Australia and the United States – two countries chosen for their opposing realities of national healthcare policy. The purpose of which was to describe the experiences and identify the similarities and differences between the two country groups to which conclusions could be drawn that suggest strengths and weaknesses of both countries and moreover, present ways in which dancers adapt to the system they operate within. The inspiration for this work came from years of reading dance medicine and science literature without understanding the actual abilities of non-company dancers to access medical and mental health care. To achieve this, a qualitative method with 230 opportunistic and chain-referral sampling was chosen to find a wide range of dancers with varying backgrounds to tell their lived stories of managing their health over time.
This research builds from the existing body of work that has investigated the dancer- practitioner relationship, communication between dancers and practitioners, the state of performing arts medicine on a national scale, and the help-seeking behaviors of dancers in countries such as The Nederland’s, France, and the United States (Air, 2009a; Alimena
& Air, 2016; Hadok, 2008; Lai et al., 2008; Manchester, 2009; Noh et al., 2003). This research adds the voice of the dancers to the body of work where data is typically created via surveys in a quantitative fashion and therefore loses contextual factors of personal history and opinions based on second-hand experiences.
Universal and market-driven healthcare. Australia and the United States were chosen as recruitment sites due to their opposing national healthcare policies. The objective was to describe the lived experiences of dancers under both systems. At the time of the interviews, health insurance being equal, all dancers had a level of health insurance; this was achieved by government insurance at reduced rates (U.S. only), employer’s paying for private health insurance (U.S. and Australia), being on the
Medicare system only (4 Australian dancers), being insured by parent’s health insurance policies, and purchasing own private health insurance (1 American and 2 Australians). I was surprised to discover nearly an even split between dancers subscribed to private health insurance and dancers subscribing to a government subsidized/public health insurance. Moreover, recent data shows just under 10% of Americans have no form of insurance, but in this sample every American dancer had health insurance. 231
The American dancers as a group spoke at a greater length about affording health insurance throughout their career. Jade, Vivian, and Benjamin each described experiencing a significant gap of time in which they could not afford any level of health insurance; Benjamin described that for his entire dance career he lacked health insurance until he began working full-time in non-dance employment where he received health insurance as a benefit. Five American dancers obtained health insurance through the
PPACA or MassHealth marketplace and paid a monthly premium fee to maintain coverage; this was even true for Nora who was eligible for Medicare, but separately was purchasing Medicare part B for additional coverage. Moreover, some of the American dancers relied on public health clinics such as Planned Parenthood or dance medicine clinics with a sliding scale fee system to allow access to healthcare services.
By contrast, Australian dancers spoke more at length about affording complementary and alternative practices such as massage therapy, yoga, and acupuncture; Harper specifically described the thrifty ways in which she afforded these practices. Moreover, Harper and Ida were the two Australian dancers who opted to begin purchasing private health insurance after they became ineligible to remain covered by their parent’s health insurance policies; both of them acknowledged they hadn’t put much thought into the decision and just wanted to remain with the system that was familiar to them. On the contrary, Yasmin and Piper both solely relied on the public system since leaving their parent’s plan; they both felt confident in the public health system but acknowledged the possibility of buying private health insurance in the future for reasons they were unsure of that time. Even with no cost for premiums, several of the Australians knew that between 1.5% and 2.5% of their income went to healthcare whereas the 232
American dancers had no way of calculating the percent of their tax that funds the several
American government health systems (VA, CHIP, Medicaid). This represents a transparency in the Australian government’s health policy that the American system lacks.
Previous literature about performing artists and health insurance acknowledges there are infrastructural barriers for dancers in small companies and non-companied
(freelance) dancers (Chmelar, 1990; Krasnow et al., 1994; Manchester, 2009). In contrast to the underinsured American dancers, Australian dancers who cannot afford to purchase private health insurance still had reduced infrastructural barriers to healthcare access by using Medicare. An example of this is the referral-managed care system that most
Americans operate under whereas Australians have direct access to and are able to be treated by a physiotherapist without involving their primary care physician; this status may explain why all Australian dancers noted they first sought care from a physiotherapist and American dancers sought care from physicians and alternative medicine practitioners. In addition, Australian citizen dancers had the psychological security of knowing they could fall back on the public healthcare system. Kat and
Yasmin had the unique ability to communicate mutual fears and confidence in the public health system while acknowledging the advantages of purchasing private health cover
(particularly before a diagnostic test became emergent as in Kat’s case). This was a stark difference to the American dancer Jade who called her government subsidized health insurance “crap, but if [she] ran out in the street and got hit by a bus it would be better
[than nothing]”; this demonstrated to me that Australians had more confidence in their public health system than Americans did with their government subsidized health policies 233
(Willis et al., 2016). The transition to being insured under parents’ health insurance policies and making decisions once that eligibility ends (and scrambling to do medical tasks before it ends) is a shared experience between both countries. In both the United
States and Australia, dancers reported very individualized ways in which they afforded the healthcare they needed such as seeking care from dental schools and community clinics; these are actions that are adaptive around the system they operate under.
In his article, published four months before PPACA was signed into law, Ralph
Manchester wrote “it is no longer intellectually honest or morally defensible to argue for a continuing role for the free market in basic healthcare” (Manchester, 2009, p. 156). He was defending the concept of healthcare as a right, which is contested and debated in the
United States by legislators. Seemingly in 2018, there is a large push for and against a single-payer system for the United States; remembering that universal healthcare is recommended by the OECD and many countries with it have better health outcomes than the United States. However, the United States is the third largest population and the current healthcare system is amazingly complex to understand to its fullest extent
(Emanuel, 2014); it is therefore difficult to propose a sweeping change in funding. The
Australian ethos equality for Australians supports the way it delivers healthcare and it took Australia years and certain leadership to enact. Tuohy noted that healthcare policy is
“essentially accidental, a product of a specific time and particular circumstances”, it is nearly impossible to predict what will happen in the coming years to the PPACA or
American health insurance (Tuohy, 1999; Willis et al., 2016, p. 49). For the advocacy of
American dancers, providing a means of accessing healthcare no matter company status or personal income would allow greater vitality in the performing arts and support to 234 dance-medicine clinics, as found when mining lessons from the Dutch national healthcare system (Air, 2009b).
Post-Patient Protection and Affordable Care Act. One reason Australia and the
United States were compared was due to their shifting national healthcare dynamics. In
2014, the Australian government proposed 7-dollar co-payment for Medicare services was unsupported and ultimately no sweeping changes to Australian healthcare legislation have occurred in the past decade (A.B.C. News, 2015). However, the Patient Protection and Affordable Care Act (PPACA) was enacted seven years before the American interviews were conducted and is moreover, a concurrent discourse in congress. The
PPACA or ‘Obamacare’ was signed into law in 2010 and its provisions were scheduled to take effect gradually over the course of the following ten years; the most contested provision, the individual mandate, took effect in 2014. Several of the American dancers reflected on how the affordability of health insurance had changed for them in the years since Obamacare had been enacted; some (Jade, Zoe, Vivian, Quinn) felt that the subsidies had made purchasing health insurance more affordable for them. Before the
PPACA offered subsidies and tax credits for low-income earning dancers (citizens), two dancers in this research went without health insurance for years and attribute several chronic health issues to a lack of preventative medicine. The act was not without complications though and one retired dancer, Nora, had seen her Medicare part-B premiums rise to more than she and her husband had been paying for Blue Cross Blue
Shield private insurance. For freelance dancers, having subsidized health insurance for low-income earners helped them to afford the service of health insurance. However, in the case of Jade, it took losing her job and making less money for her insurance premium 235 to be of value to her (the premium costing more than the penalty). The PPACA has drastically reduced the number of uninsured persons (20 million in 2017 have gained health insurance), which translates into better access to health insurance for dancers
(Bakalar, 2017). However, the PPACA also drives up costs for policies (due to the ten essentials) for middle and high-income earners. With the current Republican majority congress and administration, there are legislative challenges being made to the PPACA, including a removal of the individual mandate as of January 2018.
Companied and freelance. Employment status (companied or freelance) tended to define access and satisfaction of healthcare more so than country in this sample of dancers. Although Chmelar noted in 1990 that “unaffiliated [American] artists are often shut out of [the] health insuran-ce system completely” (Chmelar, 1990, p. 67); the current findings did not support this. All dancers at the time of the interview had some sort of health insurance, though it is worth noting that Jade had become insured for the first time in her adult life just two months prior. Some dancers in the study were dance teachers, but they too could be divided between instructors with a full-time teaching load (Nora) and dance teachers who were patch working their schedules together like a freelance dancer (Harper and Yasmin).
Nearly half of the dancers were companied, full-time teachers at a company, or a director of a company. The five dancers who were companied shared several ways in which healthcare access was built into their employment. Emerson described a ballet coach who directed his dance-specific rehabilitation program, Sam had a company supported health savings account to use for any out-of-pocket expenses, and both
Emerson, Gwen, and Liam had in-house physiotherapy within the large ballet companies 236 they worked for. A barrier for dancers in large companies was the touring schedules that naturally resulted in limited time frames in which they could schedule appointments and receive medical or mental health care. Another barrier companied dancers expressed were unsupportive company directors; this was especially true for Olivia who expressed that after sustaining an injury, her company director treated her poorly.
It is typically difficult to study professional freelance dancers as a single homogenous group due to the possible combination of dance networks, contracts, athletic-level, and genre each being specific. The struggles that the freelance dancers expressed appeared different than the struggles (barriers) the companied dancers spoke of during data collection and analysis. For one, freelance dancers described the cost of healthcare and health insurance as a prohibitive factor; some freelance dancers had years without health insurance and relied on sliding scale and community-based clinics.
Moreover, some freelance dancers struggled with obtaining referrals, developing their medical network, and overcoming a knowledge barrier concerning health insurance.
Specifically, the Australian freelance dancers struggled to be understood and accepted; several contemporary freelance dancers in Sydney felt that the physiotherapists associated with the large ballet companies were not able to curate treatment to their needs. This echoes Hadok’s description of a performing arts medicine system in Australia as providing “quality performing arts healthcare” to company dancers, but not freelance dancers, and “on a poorly organized basis” only in large cities (Hadok, 2008, p. 83). Non- companied dancers had to exercise thrifty behaviors to adapt to the system they were in whereas the companied dancers struggled more with healthcare in times of touring. 237
Dance-specific care. Being curious and open to learning about dancers and their demands was mentioned as a desired quality that practitioners could demonstrate. Sam, an American companied dancer, further described dance-specific care as taking a
“broader look at the body” rather than having “tunnel-vision” in terms of the diagnosis.
Nearly all of the dancers had seen a healthcare professional that they considered to be
“dance-specific.” The experience of dance-specific care was markedly different between the two groups of dancers (Australian and American).
Nearly all the American dancers noted that they had access [by proximity] to a renowned dance-medicine clinic whereas the Australian freelance dancers noted they had limited access to dance-specific providers, difficulty communicating with the company- associated physiotherapists, and that those therapists demonstrated inflexibility when asked to manage the care of a freelance contemporary dancer (in contrast to a full-time ballet dancer). Their stories corroborated that the known dance-specific physiotherapists
(the clinician type which Australian dancers tended to seek out most when injured) were employed by large ballet or modern dance companies in Australia; one freelance dancer referred to the situation as a “closed-circuit”. American dancers were likely to know of a nearby dance medicine clinic, however not all dance-specific care was a positive experience; several of the American freelance dancers described one of the two dance- medicine hubs as unwelcoming, rushed, feeling misunderstood, and expensive.
There are professional organizations in both the United States and Australia that represent performing arts medicine professionals; this demonstrates a cohort of professionals who are dedicated to the wellbeing of performers. However, unlike sports medicine that has a developed system to embed healthcare professionals throughout the 238 training and career of athletes, dance medicine is typically absent until the professional company level.
Patient education. A first unexpected theme to emerge was knowledge of body. It involved stories of dancers formally or informally learning about their body and health maintenance behaviors. The types of information that were discussed or demonstrated in the interviews encompassed topics of anatomy, biomechanics, pathomechanics, help- seeking thresholds, and therapeutic interventions such as self-mobilization and therapeutic somatic practices. Some dancers spoke directly about past injuries thus implying knowledge, while other dancers directly described the types of knowledge they had gained through their development. Several dancers described learning about their body as a positive result of having excellent communication with their medical provider, while poor communication was typically indicated by a lack of perceived lack of learning.
The task of learning was accomplished through secondary, higher, and professional education, from healthcare and mental health professionals, as well as through self-directed education. In their sample of 486 dancers, Kotler et al. found that
67.2% of dancers had taken an anatomy course, most often being a college level science course or training in bodywork or movement-based therapies (Kotler et al., 2017, p. 78).
The majority of dancers told stories of learning about anatomy or rehabilitation methods after becoming injured and becoming a patient of a healthcare professional. Several dancers described learning about psychological strategies to manage conditions such as depression or anxiety from a professional counselor or psychologist. In contrast with the
Kotler et al finding that years of dance training and professional dancer status both 239 significantly correlate with increased knowledge of anatomy but not perceived knowledge, all dancers in the current research perceived, at least represented, themselves as more knowledgeable now than prior in their career (Kotler et al., 2017). It is a possibility that ranking one’s perceived knowledge of anatomy while also being formally tested on the subject may lower self-efficacy of anatomical knowledge compared to when providing contextual examples of the same knowledge in an interview/storytelling setting.
Kotler et al. proposed that dancers’ increased knowledge of basic anatomy may
“contribute to preventative care, aid in compliance with treatment, and augment the results of medical interventions, therapies, and training programs”. (Kotler et al., 2017, p.
77). The dancers noted that increased knowledge of the body enabled them to be more capable of managing injuries, identifying warning signs, knowing involved anatomy, and understanding the injury rehabilitation processes of injuries they’ve sustained than when they began dancing. Secondary benefits of knowing more include a greater capacity for self-care and injury prevention, increased ability for in-depth conversations with medical professionals, as well as the ability to share information with peers and students. The practical consideration of this theme relates to patient education on behalf of the medical or mental health professional. The importance of learning from medical and mental health professionals was repeated over and over in the interviews. I postulate that because dancers are “accustomed to being instructed, directed, corrected, and are goal-directed” that these qualities relate to how the dancers in this study were driven to know more about their body, their rehabilitation, and prevention techniques (Greben, 2002, p. 20). 240
Non-conventional healthcare. Complementary and alternative medicine (CAM) was not typically named as such, but practices and concepts around CAM were frequently present making it the last major emergent theme of the interview data.
The variety of alternative and somatic practitioners are presented in chapter two; the dancers reported the most experiences with acupuncturists, massage therapists, Pilates instructors, Yoga teachers, Feldenkrais Method practitioners, and Alexander Technique practitioners. Conventional practices named were the following: physician, a sports medicine allied health professionals (such as athletic trainers, sports physiotherapists, or physical therapists) and perhaps sports psychologists and nutritionists.
There was no literature found that specifically explored dancers’ use of CAM or the effects of CAM on dancers’ health. In Norway, researchers found that musicians tended to use alternative practitioners more than the general public, one theory being that as creative people, musicians are more open to alternative avenues (Vaag & Bjerkeset,
2017). The dancers in the current research expressed an openness for therapies that were suggested to them by fellow dancers or therapies which they predicted were holistic in nature. Australian dancers Alynn and Harper noted that Somatic practices were useful for grounding their movement and increasing “mind-body awareness”. The Australian dancers tended to speak about alternative or Somatic practices for physical maintenance while the American dancers tended to speak about the same therapies for injury rehabilitation. A commonality between the two groups of dancers was the wish that massage therapy specifically, would be covered under the private health insurance policies. Many dancers turned to massage therapy as a healing or preventative therapy, 241 but most paid out-of-pocket for the service (all except the Australian companied dancers who enjoyed in-house complimentary massage).
General Implications
The stories that dancers shared for this work demonstrates a desire to continue dancing despite the risk of injury, despite the burden of psychological strain, and despite the improbable chance of being well-paid and well-supported as a company dancer. The importance of this research is to support and care for a profession that adds vitality to a well-rounded arts culture and moreover, introduce their lived experiences and opinions about healthcare into the research that is consumed by the professionals caring for them.
A running theme in the work was the dancers’ speaking about their body as facility and the ensuing frustration when medical professionals didn’t recognize that importance and need to keep dancing (Greben, 2002; S. Nordin-Bates et al., 2011). The importance of the dancers’ facility as both a tool of expression as well as the key to their livelihood was demonstrated repeatedly. Understanding dance as an occupation more than as an artistic endeavor reflects back to the artistic-athlete or athletic-artist debate
(Kaufam, 2015). This was not a question proposed in this study, but it arose with several dancers. Acknowledging that sports are more widely experienced by both Australian and
American citizens, reasons for subscribing to the artistic-athlete model would be to increase services equivalent to those traditionally seen in sports medicine. Reasons for subscribing to the athletic-artist model would be to acknowledge that dancers are artists at the core of their practice with athletic capabilities; however, the former, again, is more aligned with accessing greater medical services. To this notion, dancers should approach their medical care with a similar attitude and be personal advocates of the physicality of 242 their artistry. Many of the dancers’ stories relayed a sense that not all medical or mental health professionals demonstrated respect for this physicality, therefore, dancers need to be empowered to either change clinicians or advocate for themselves; this is an attitude I suggest is placed within dance curriculums at all levels.
From a methodological standpoint, it was intuitive in the choice to bring dancers’ stories about healthcare via an interview method to the forefront. Collective knowledge about dancers comes with profession stereotypes, such as perfectionism and body-related issues (Cumming & Duda, 2012); this was a common issue voiced by Australian contemporary dancers in relation to physical therapists who were rigid in their knowledge of ballet medicine. Sharing dancers’ stories and thought processes provided insight on how this population has grown and adapted around the limitations of healthcare. For example, a common solution found amongst dancers was paying out-of-pocket for massage therapy as several dancers found it to be a useful physical maintenance tool.
Understanding the history of how dancers develop their healthcare perspectives encourages an understanding of the nuance of genre, workload, and the individual; when this curiosity is expressed in clinical practice, in turn dancers feeling better understood should increase the rapport between dancers and medical professionals (Alimena & Air,
2016; Lai et al., 2008).
Implications for Healthcare Professionals
For healthcare professionals interested in improving their services for dancers, and for clinics that focus on dancer health, I direct their attention to several suggestions to achieve these goals. To address these, three implications for dance medicine clinics are presented followed by five suggestions for individual practitioners. 243
Several Australian dancers who went to the same performing arts conservatory expressed a pattern of low mental health and medical support while they were students.
In the United States, several dancers who attended select performing arts high-schools and conservatories had access to in-house medical services of which they expressed appreciation and utility. To align the future of dance medicine with sports medicine, supporting dancers from a pre-professional level encourages long term relationships with healthcare and physical wellbeing, setting dancers up for more knowledgeable professional careers as they continue to heavily rely on their body. There are already several American universities that have established a dance medicine clinic to support the dancers in their dance programs (John Hopkins Medicine, 2018; Shenandoah University,
2018; The University of Arizona, 2018). In addition, establishing dance clinics that are not attached to a dance company would positively support those freelance dancers who shared a difficulty accessing dance-specific physiotherapists. This suggestion is mirrored by Vassallo’s recent research, which stated “other countries have established specialized clinics…specifically designed for part-time and freelance dancers. This study provides evidence that such a service would meet a need in Australia” (Vassallo, 2018, p. 8). From the current study, I believe that such a clinic would have helped the various Australian freelance dancers I spoke with in their efforts to access timely and specialized care.
While also supporting pre-professional dancers, the next two implications for dance medicine clinics are to have a robust referral network that includes mental health services as well as complementary and alternative medicine (CAM) professionals. An emergent theme was that dancers turned to non-conventional medicine to maintain health and wellbeing, (such as regular massage appointments) praising acupuncture as a treatment 244 from their general physician or establishing a long-term primary care relationship with chiropractors and yoga practitioners over physicians. Moreover, several American dancers mentioned a past need for mental health but found it too expensive and instead relied on their primary care physician for mental health support. I suggest that dance medicine clinics develop robust systems of communication and referral with mental health professionals as well as CAM professionals. On a larger scale, I propose (even though some organizations are already doing this) an easily accessible database for dancers to learn about dance-specific or dance-knowledgeable clinicians around their perspective countries (or touring country need be).
Purposefully growing a professional network will aid in moving towards an
Integrated Care model within dance medicine clinical programs which are currently mimicking the established sports medicine model (allied health sports medicine professional collaborating with a sports medicine physician). Integrated care promotes a collaborative approach between medical and behavioral health professionals and has been proposed to “improve the individual's experience of healthcare” (Substance Abuse and
Mental Health Services Administration, 2018). Integrated care is more involved than the medical team approach that athletics have established (coaches, athletic trainers, sports medicine physicians). An integrated health model with a physician, physical therapist or athletic trainer, mental health professional, a nutritionist, and a somatic practitioner would be an ideal collaboration to manage dancer wellbeing. Moving from coordinated care (communication), to being co-located (physical proximity) to finally, having an integrated practice of multiple healthcare professionals (practice change) should be a desired goal of dance medicine programs (Heath et al., 2013). 245
Implications for individual healthcare professionals working with dancers are: including education in clinical practice, listening to outcomes from complementary and alternative medical (CAM) practices, utilizing an inter-professional referral network, viewing dance performances, and learning more about various dance genres. Including education as intervention into clinical practice speaks to one of the largest emergent themes presented in the previous chapter. Kotler acknowledged that dancers learn from being injured and in a formal education setting (Kotler et al., 2017); the dancers in the current study expressed appreciation for the information they’ve gained from going through the injury process or from seeking counseling services. Education about anatomy, injury prevention, and nutrition for example, can be shared alongside clinical practice, or in workshops, while working individually with dancers, within a formal class setting, or through dance-community outreach; however, the majority of dancers noted their knowledge came from direct clinician-patient contact.
While CAM practices are not synonymous with holistic care, most dancers used the concepts and applications interchangeably and moreover, they were spoken about favorably when compared to conventional medical professions. In alignment with moving towards integrated care, individual dance-medicine practitioners can open up their referral network to CAM professionals in addition to mental health professionals.
Utilizing an inter-professional network was praised by the several dancers who experienced it and when it was missing, it was desired by others. For example, Sam said
“people want to do whatever it is that they do to you regardless of whether it is the right thing...they want to [perform] surgery on you if that’s their thing, they want to give you a steroid shot if that’s their thing”. He was suggesting that medical professionals, both 246 conventional medical professionals and CAM professionals, become stuck in referring patients back into the system within which they themselves operate. With patient- centered care in mind, medical professionals working with dancers should work towards familiarizing themselves and accepting the helpful mechanisms of different assessment and treatment methods. Healthcare professionals working with dancers can work towards understanding and collaborating with healthcare professionals who operate under different ethos?
Finally, to improve rapport with dancers, healthcare professionals should attend dance performances and expose themselves to various dance genres. Lai et al found that
“the single variable of greatest importance to dancers was the frequency with which practitioners observed dance” (Lai et al., 2008, p. 50). This especially may address the concerns of the Australian contemporary dancers who often voiced that the physiotherapists they knew struggled to think outside of a ballet framework. Attending dance performances demonstrates a dedication to the performing arts as well as adds to a shared experience between dancers and healthcare professionals.
Limitations
There are limitations present within this study. The most glaring of which is the inability to generalize the results to larger groups of dancers. The in-depth stories of each dancers’ healthcare experience are presented to be their own, and not representative of all dancers. Therefore, the recommendations presented are based on the emergent themes of the 20 dancers interviewed. Considering the sample interviewed, it is a possibility that the dancers who answered an advert for this research had an interest in the topic of healthcare and therefore volunteered. This would somewhat bias the responses. Considering bias, 247 this study took place in two countries while the primary investigator was American; in some regard, the interviewer may have made assumptions of the American dancers and not with the Australian dancers; for example, having asked more clarifying questions of the Australian dancers than for the American dancers.
There was an attempt to include a diverse sample of dance genres, historical, improvisation, tap, and Irish dance were included alongside the majority of contemporary/modern and ballet dancers. This was an accomplishment to be able to include the variety there is, however in the future, quota sampling may be used to ensure equality between representation of any genre. Finally, a limitation in discussing freelancers is that there is a wide variety of what it means to be a freelance dance artist; in an attempt to discuss them as a group some nuance was lost.
Future Research
I would like to present several suggestions for future directions of this research topic. A strength of this work was allowing dancers to self-identify as professional; this allowed for a more diverse sample leading to a broader understanding of dancers’ experiences of healthcare. Future research should explore this method to explore the many pockets of dance. However, recruitment was challenging and therefore creative measures should be considered.
Many dancers in the current study noted the utility of worker’s compensation and alternative medicine practices on their ability to recover from injury and have access to healthcare. In performing numerous searches in past literature, a dearth of publications explored either of these topics in relation to dancers. Prominent performing arts medicine journals had published about alternative and complementary medicine (Vaag & 248
Bjerkeset, 2017) and Workers Compensation concerning musicians (Chimenti et al.,
2013; Chmelar, 1990). Similar work should be conducted with dancers because of its emergence in this study.
Additional qualitative research should be performed with dancers to reveal the decision-making process in help-seeking behaviors. From the current study, I was fascinated by either the isolated instances or familial influences that would shape the dancers’ perception of healthcare. An exploration of these contextual may provide greater insight as to why dancers choose the healthcare professional they do, such as how all
Australian dancers opted to seek care from a physiotherapist first.
Conclusion
This research describes 20 dancers’ stories describing their past career and experiences with healthcare. Several emergent themes were identified such as knowledge of body and complementary and alternative medicine as well as an exploration of managing pregnancy as a dancer. Moreover, several similarities and unique aspects of healthcare experiences were described between the American and Australian dancers.
This work supports the notion that dancers respond well to medical practitioners, mental health professionals, and Somatic practitioners who care about dance and want to treat them holistically. It also supports the thought that freelance dancers in the United States have and do struggle to afford basic healthcare services.
249
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Appendix A: Institutional Review Board Approvals
2016, 2017, 2018: The Ohio University
2017: The University of Sydney
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Appendix B: Pre-interview Survey
1. Current employment situation: (Chimenti et al., 2013) A1 [ ] – Currently working A2 [ ] – On paid leave A3 [ ] – On unpaid leave A4 [ ] – Unemployed A5 [ ] – Retired (not due to health) A6 [ ] – Disabled and/or retired due to dancing-related injury A7 [ ] – Disabled due to health problem other that dance-related injury A8 [ ] – Other
2. Do you consider yourself a professional dancer? (Jeffri et al., 2011, p. 26) [ ] Yes, please choose from the following options (check all that apply): (Jeffri et al., 2011, p. 26) A1 [ ] – I consider myself a dancer A2 [ ] – The main body of my activity is some form of dance A3 [ ] – I have a demonstrated record of performance or other evidence of my dancing A4 [ ] - My main priority is to dance A5 [ ] – I spend the majority of my time dancing A6 [ ] – I have been formally trained/educated as a dancer A7 [ ] – I make my living as a dancer [ ] No
3. Optional: if you could estimate, how much money do you feel you pay out-of- pocket for health services (inc. co-pays, gym memberships, and OTC medications/supplies)? (Original question)
$______(USD) $______(AUD)
4. Optional: if you could estimate, what is an average yearly salary for you? (Original question) $______(USD) $______(AUD)
[Please continue to backside of survey]
5. Have you experienced being pregnant while also being a dancer?
[ ] Yes [ ] No
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6. Do you have a primary care physician / general practitioner?
[ ] Yes [ ] No
7. Have you experienced an injury that kept you from dancing for more than one day? (Please circle)
[ ] Yes (if yes, please continue to questions 8 – 14) [ ] No
8. Did you / do you continue to dance despite being injured? (M. E. Air, 2013) [ ] Yes [ ] No
9. If yes, how many hours per week did you/do you dance despite being injured? (M. E. Air, 2013)
______hrs/week
10. When you FIRST injured yourself, from whom did you FIRST seek help? (M. E. Air, 2013)
[ ] Dance teacher/ Music teacher [ ] Physiotherapist / Physical Therapist [ ] Athletic Trainer [ ] Masseur/masseuse [ ] Alternative medicine practitioner: acupuncture, etc. [ ] Chiropractor [ ] House doctor (MD) [ ] Medical specialist (MD) [ ] Other: ______
11. How much time passed between your FIRST becoming injured and first seeking treatment from a medical professional? (M. E. Air, 2013)
______years/ months/weeks/ days/ hours (circle)
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12. How satisfied are you about the medical care you received so far? (M. E. Air, 2013)
[ ] Very satisfied [ ] Moderately satisfied [ ] Neutral [ ] Moderately dissatisfied [ ] Very dissatisfied
13. How long did you have to wait for an appointment? ((M. E. Air, 2013)
______Months/ Weeks/Days/Hours
14. In your opinion, what is the most important aspect of your treatment for your dance related injury? (M. E. Air, 2013)
[ ] Elimination of pain [ ] Good relationship with provider (good listening skills, empathy, etc) [ ] Ability to return to my pre-injury level of dancing [ ] Other: ______
For the purposes of identifying you in the report/dissertation/potential publications, please choose 1 or 2 pseudonyms to mask your identity: (list of 26 names) Appendix C: Interview Guide
Warm-up Questions (Q0.1 – Q0.6) 1. Please walk me through your development as a dancer from the beginning to today. 2. What does the word healthcare mean to you? a. Does this include mental healthcare? How often do you think about health insurance? What is your experience of being a dancer and accessing the healthcare services you need? Part One (Q1.1 – Q1.2) 1. Can you tell me about a time when you’ve been injured that got in the way of dancing? a. If yes, how did you manage the [example injury]? b. Did you receive financial support to seek treatment? Mothers: How did pregnancy, dancing, and healthcare intersect? Part Two (Q2.1 – Q2.8) 1. What have been your expectations when seeking a medical professional in terms of access? 2. Besides health insurance, are there any other barriers to accessing health services you’ve needed? 3. Are there factors such as services, programs, or people, that have helped you access healthcare services? 4. Do you feel like your current and employers are/have support/ed your healthcare needs? 5. Which of your past experiences/companies offered you health insurance? a. If not, how did you manage not having insurance? Have you experienced gaps in health insurance coverage or the feeling you were under insured (inadequate insurance coverage)? Have you used community services (such as open or public clinics) for your healthcare needs? 266
Between completely unsupported and fully supported, what level of support have you felt as a dancer from clinicians? From institutions/your employers?
Part Three (Q3.1 – Q3.7) 1. What do you want out of healthcare? a. Follow up: Either structural or individually from professionals? Could you tell me more about your experiences interacting with physicians or other allied healthcare clinicians (such as athletic trainers or physical therapists?) . Have you seen a dance-specialist or have your past clinicians had experience with dancers? a. Have you felt satisfied with the services you’ve received for dance-related injures or dance-effecting illnesses? What have been your experiences communicating your needs, as a dancer, to medical professionals? How do you feel about overall quality of care that you’ve experienced recently? How do you feel about the network of providers available to you currently? How do you feel about the range of covered services by your current health insurance? Are you satisfied with the healthcare you’ve received when seeking dance-related care?
267
Appendix D: Brief Summary of Dancers
American Dancers
Vivian. Vivian was the most transient dancer, having spent the past ten years consistently dancing between Boston and New York City. She had a 17-year full time dance career in Boston, but made the shift to partly teach and continue dancing between the cities. Vivian struggled to trust insurance companies and the medical community. She had gone through a six-year uninsured period in the 2000s; during this time, Vivian sustained a tooth infection which was sequenced to a slew of related injuries and conditions that lasted 2.5 years. More that that, Vivian also described a 20-year foot pain which she had sought care from at numerous hospitals and through numerous physicians.
Currently, Vivian has a positive relationship with her primary care physician, calling her
“outside of the box” which she appreciated.
Nora. Nora began tap dance as a child but stopped practicing as a teenager. She picked up the art form again as a second career after having two children and getting married to a physician (having met him from working in a hospital). Her experience was vastly different as she had healthcare through her husband’s employer and moreover, through professional-connections, he was able to get Nora top-notch doctors in the
Boston area when she had a medical need. Another unique factor, was Nora was the only
American dancer who had experienced the Patient Protection and Affordable Care Act to create a greater expense for her husband and her to afford health insurance (Medicare).
Fern. Fern is a newly minted dance graduate out of Boston who had just moved to New York City to pursue the “professional dancer game”. Fern had many experiences with complex undiagnosed injuries, mostly muscular strains, which she feels have 268 strongly influences her dancing styles of improvisation and contemporary. She’s always been able to access dance-specific medical professionals, but had both positive and negative experiences with them. Fern was the youngest interviewee and was still insured via her parent’s insurance policy
Sam. Sam grew up dancing in his parent’s studio in New Hampshire. He earned his Bachelor’s in Dance Performance and was quickly recruited into a well-known contemporary dance company in the United States. Sam noted that he trains like an
Olympic athlete but finds the medical care available to him not at that level of rehabilitation expertise. He had sustained several (neck and back, muscular involvement) which he was currently continuing preventative exercise for. His company provided him health insurance and a health savings account, his largest barrier to seeking care was time and finding a specialist when he was on tour. Sam was an advocate for holistic care and stressed the importance of listening skills for physicians, which he often felt they lacked.
Jade. Jade was a contract-based dance artist in New York City. She earned her
Bachelor’s degree in the United States and her Master’s in London. She was at a point in her career that she no longer truly auditioned for roles, but was known by several companies and was more often contacted to dance. Planned Parenthood was “pretty much it” for Jade in terms of healthcare; she was a long-term uninsured American and had only recently obtained a health insurance policy through the subsidies the Obamacare marketplace offered her. She noted that no company that she has worked with offered
Workers Compensation and she has relied on sliding-scale clinics to find affordable physical therapy for her past injuries. 269
Zoe. Zoe was currently dancing in her own co-owned company. She had taken a break from dance between her teenage years and mid-twenties until she realized she was a kinesthetic person and wanted to peruse dancing professionally. She auditioned for an experimental theater company and calls this her gateway back into performing. From athletics she had undergone an ACL reconstruction surgery and was currently dealing with a possible resurgence of Lime Disease. Zoe stressed the importance of holistic care and noted that through Obamacare tax credits, she was able to afford health insurance as an artist.
Olivia. After a long career of studying ballet (earning her bachelor’s degree) and performing ballet in a professional New York company, Olivia sustained an injury two years prior and had been a freelance dancer since that point. She described her parents as
“hippy-types” in respect to leaning more on natural remedies than conventional medicine.
Olivia was diagnosed with Celiac disease in high school which was her largest and more long-term medical expense. Moreover, Olivia seemed to have sustained injuries to the most joints of any dancer I spoke with, she has undergone surgical correction (ankles) twice and ended up leaving her professional company because of the negative attitudes surrounding seeking care for pain and injury.
Benjamin. A part-time Baroque dancer, Benjamin has retired from a full time freelance dancing career and was working for the university when we met for an interview. Benjamin has danced in several American cities as well as Paris performing late-Renaissance and Baroque styles. Benjamin went years without health insurance and finally afforded it when he began working for the university. He expressed that it took 270 time and patience to find quality physical therapists to work with in Boston, but he is happy with the current clinicians he had found through personal referrals.
Coral. Coral’s dance training is rooted in Irish dance – having performed and toured as young as 9 years old. She transitioned to contemporary and modern classes and earned her Bachelor’s degree in Communication and Psychology. Currently she is a full time high-school dance teacher, co-owner of a project-based dance arts company in New
York City, and occasionally tours with an Irish dance company. Coral relies on a 10-year relationship with a chiropractor as her primary point of care and spoke at length about her preference for holistic care. Her frustrations were centered in a breakdown of communication between medical practitioners and how as a young dancer she was encouraged to push through pain, a practice she consciously works to correct in her own teaching.
Quinn. Quinn was the only Broadway dancer included in this work and moreover, she was also an actor who had danced on stage and film. At the time of our interview, Quinn was getting ready for an scheduled surgery to relieve chronic back pain she was having. Quinn had experience with shopping for her own health insurance as well as affording health insurance through the Screen Actors Guild. Moreover, she had sustained several injuries both on and off stage in her career. Quinn’s husband was a therapist of several somatic and manual body work techniques and was her primary medical support.
Australian Dancers
Piper. Piper was 6-months pregnant with her first child and had recently made the call to refrain from dancing for the remainder of her pregnancy. Piper stressed how 271 unpredictable her workload over the course of her career had been; a contract-based dancer, Piper sometimes is working on multiple performances and sometimes has periods with no work. Her most serious injury was a muscle strain which took three months of no-dancing to heal – other than that she’s “been lucky not have had anything [else] serious”. Regarding seeking medical care, both for her pregnancy and past injuries, Piper has found it frustrating to not feel understood by physiotherapists or physicians. She felt they misinterpret what kind of dancer she, therefore felt their medical advice was misinformed.
Alynn. Alynn’s dance training began in commercial and contemporary roots and ended with a Bachelor’s degree in dance from conservatory in Western Australia. She was employed at a small-to-medium sized dance company. A challenge in her healthcare is the lack of under-study performers which in one example, required her to “modify for months” as an injury slowly healed. Alynn has private health insurance in addition to the insurance her company affords her.
Harper. Coming from a very supportive family and early dance training, Harper went to a distant dance conservatory for university and earned her Bachelor’s degree in
Ballet and continued there to earn her Master’s degree Dance and Creative Practice with
“a little bit of Anthropology”. While in university, Harper described several mental health issues including struggling with memory in dance, anxiety, and moreover noted that eating disorders were highly prevalent. She describes healthcare as a process of maintenance and employs Yoga and the Feldenkrais method classes to maintain her own health. Harper was currently affording her own private health insurance while teaching 272 dance at multiple locations, managing a dance space, and continuing to choreograph her own work.
Una. Una was a retired professional dancer who was currently working for two large dance companies in an administrative role. She had danced ballet for a company in the Netherlands for seven years and a company in Australia for three years. She left her professional dance career to begin a family, a choice she noted current professional female dancers don’t have to make. Una felt that being a dancer was an occupational hazard and that her whole career was spent figuring out ways to create movement without causing injury. She notes she was fortunate to have a facility suited well to dance and just once suffered an injury on stage (a shifted vertebrae). Una continues to learn having earned a Bachelor’s degree in History and Politics in her forties and remains an advocate for dance.
Gwen. Dancing since she was three, Gwen began serious ballet training at the age of 13. She had and overcame an eating disorder in her teenage years. She has danced in
Germany, the United States and Australia. She danced ballet for a large professional ballet company in Queensland, Australia. After one year of companied dancing she opted to have surgery to correct bilateral jumpers knee and made the decision to transition into teaching full time for the same company. Gwen is the youngest Australian interviewee and was still had private health cover via her parent’s policy.
Liam. Liam is a professional companied ballet dancer who spoke of personal resilience and demonstrated his sunny disposition take on challenges. Liam sustained a three-time recurring back injury as a teenager that taught him a lesson about respecting healing times and about his own anatomy. He has learned a lot through his physiotherapy 273 sessions from his youth as well as from his Pilates instructor. Liam advocates for more dance science within the dance world, he would like dance to be at the same level as other athletic sports in terms of their sports medicine support.
Emerson. Emerson is a foreign-born companied dancer in large ballet company in Australia. His dance training began at age 6 and he finished his training at a ballet high-school in the United Kingdom where he was directly recruited from by his current company. Emerson has had two significant injuries; the first he mostly rehabilitated himself due to a lack of priority by the company physiotherapist when he was a student in the U.K. The second injury was current and he was working with his company’s physiotherapist and ballet coach to move through it. Emerson had also utilized the company sports psychologist in the past and valued all the services he had available to him free of change. He does purchase private health insurance due to his immigrant status.
Yasmin. Yasmin was participating in dance training from a pre-school age. She went on to earn multiple higher education degrees in Dance Performance. Ultimately, she decided she enjoyed teaching and being backstage more than performing on stage; at the time of our interview, she was teaching dance full-time between several studios in
Sydney. She feels that one of her past dance teachers was too harsh and cruel about critiquing her body but ever resilient, Yasmin stated she always knew her diet and body were healthy. Yasmin was on the public health system (Medicare) and feels she has received equally satisfactory care from private hospitals and public hospitals from her injury and illness experiences. 274
Kat. Kat began intensive ballet training at a young age and later transitioned into contemporary dance through an honours program. After university, Kat was a freelance contemporary dancer for three years and at the time of our interview was a dance teacher for students with physical disabilities as well as a Pilate’s instructor. At the time, Kat was struggling with a gastrointestinal issue, that without private health insurance, had cost her
3000 dollars out-of-pocket to expedite the tests (medically recommended). She attributes the cause to years of ingesting ibuprofen for pain as she was dancing without the knowledge to eat food with the medication. For this reason, Kat was an advocate for more nutrition and diet information to be added into dance programs.
Ida. Ida’s passion for dance began in primary school and through mentorship she made the decision to study dance in university. While studying Ida notes learning a lot about the body and it’s mechanics, but also a lack of information about the psychological side of dance such as eating behaviors. After one year in the program, Ida was managing homesickness, a lateral ankle sprain which became a tendinitis which cumulated into a breakdown at her end of year review. She took a year off to seek psychological support for depression and returned after to complete her degree. At the time of our interview, Ida lived outside of Darwin and noted her largest barrier to healthcare was her location – finding a dance-knowledgeable clinician near her was difficult. She was employed as a dancer for a community-based dance theater company.
275
Appendix E: Two Example Transcripts
The ‘J’ in the transcripts are the interviewer (Jill) and “Z” indicates Zoe was speaking while “H” indicates Harper was speaking.
American Transcript: Zoe
J My parents did the same thing and my mom insured my husband for, her husband my father for a number of years,
Z Yeah so I stayed on his insurance for quite some time so I guess that during that stretch of time, I continued to have small moles and things removed cause they are really careful cause of I had a melanoma. I did have um I did have a precancerous cell on my cervix, so
I had a kind of a number of, I didn't end up having a procedure but additional gynecological appointments during that time, I ended up going away so I never had to have a procedure. What else? Hmm I mean orthopedically I have had a bone stress fracture in my left foot so I have MRIs on that foot um j Is that a current thing?
Z Yeah I mean it is current, it's never really I just work with it, I mean it’s an old injury that was caused by having a really bad bunion on that side so I have been , I have seen a couple of doctors over time about my foot, the it’s just the bunion causes transverse pressure in to that second metatarsal caused the bone fracture which now there is like soft tissue inflammation and bone spurs and kind of arthritis around that area, It's like my body I just end up with arthritis in places where I have had injuries, so my foot did that and now my knee.
J Same side? 276
Z Opposite side, um it's the one that had the ACL reconstruction and you know now everything is wrong with it, I have Bakers Cyst and bond spurs and no medial meniscus and three tears in the meniscus and my patella is misplaced and everything, it's all of the things and my QL is 30% weaker so I mean my quad is significantly weaker. So yeah, I you know I dance with those injuries, I deal with them, there is nothing they can do for my foot until maybe I have the bunion surgery.
J What kind of things, I mean do you do things, do you always tape them do you wear knee wraps...
Z I wear knee pads when I dance just like kind of contact, knee pads just for that extra, sometimes I wear a neoprene brace on the right, I take a lot of ibuprofen. I do go to physical therapy when I have the time or when I am leading up to a show and I need to be stronger. and I mean that's primarily it, I can't afford body work, in my budget, I wish I could, I wish that was included, I wish that was covered in my healthcare.
Australian Transcript: Harper
H Yeah that was the last time
J And then you saw somebody else?
H Yes, but who did I see though, I feel like it’s still a little bit where I can progress and then I saw a physio that is just down the road, that’s really close to me ..um and he was fine but he is not amazing and I still see him but I feel like I am OK because I had those other supports.
J the massage, the Pilates, the doctor
H Yep, yep and I had my scans and my x-rays and all that sort of crazy stuff as well and it all happened really fast 277
J What happened to your knee?
H I was doing this movie, last year, before this lovely organization and I it was really cold and we were dancing in the middle of winter around this time and we were dancing in this old mental asylum and I was kind of going for it and I twisted my knee and um straight away it swelled and I couldn't straighten it but I kept...it was pretty far, but I kept going because there was nobody else. And we were..
J Were you the only dancer in the film?
H Two dancers one man and one woman and there's like the thing about film is there are about thirty people there to help get this thing out so for me to say, I have to stop,
I obviously didn't know and I also was a bit in shock as well, I just kind of holed off and then I had to get my friend to help me massage it out, because I thought it had just locked up um but I and then I just watched it for the rest of and then I went home and had a bath and thought i had taken care of it and thought I had just wrenched it or something which is what happened but I but I partially tore some of the ligaments at the back of the knee and couldn't lift my knee up properly so it took me maybe two months to go…something is off, I need someone to really ... and then that physio that I don't like was like.....no no, it is really bad and you need to go and get all these things done and so then I did
J So was the physio, the company physio you mentioned, the first person you told
H I think so.
J First professional healthcare, maintenance professional
H Maintenance professional, Yeah I think so, maybe I 'd told my masseuse, but he just helps me release it and then bending was pretty painful and sore to touch and now that is all gone but yeah, yeah 278
J OK so when you were going through
H One of the things that was another it was frustrating me about this physio was that her kind of distaste of something, for the fact that it had taken my so long to say something, and I really didn't appreciate that and she couldn't understand what I was doing or why I needed to be, cause I was no I need to be able to ....she didn't really want to treat me, I felt she didn't want to treat me cause she didn't understand that I needed to get back to a peak, I needed my body to do everything that it could and she couldn't understand why that was , but she was like a dance company physio and I was like....
J Did other dancers have good experiences with her?
H yeah, yeah, not everyone, actually I have heard mixed results, she is like the protégé of someone who was fucking amazing but unfortunately that person, I think she is in Europe and this is the new and she is young and comes through a particular trajectory through the dance world that doesn't understand that there are other ways. Does that make sense?
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Appendix F: Codebook
Injury Story - stories of being injured from beginning to end.
Comments about dance - comments on dance custom Barrier to Dance - any obstacle to overcome to be able to return to dance (rehab) Determination - showing drive to be a dancer (look into this) Connection to dance - passion for being a dancer Dance development - backstory of how they trained to be a dancer Dance pedagogy - experiences of learning and current teaching philosophies Dancer network - peer to peer medical recommendations (seeking care) / (resourceful)
Navigate health services experiences - stories shared that left the dancers wanting more or unsatisfied with care Barrier to care - factors that limited the dancers ability to either afford or access healthcare
Knowledge of Healthcare system - demonstrating a knowledge of “the system” or some prowess about navigating the Knowledge of own body - dancers awareness for their own anatomy and biomechanics as well as the process through which they learned about their anatomy and biomechanics Thinking about healthcare question - answers to the question “what is healthcare” Healthcare support - answer to the question: on a scale from 0 - 10, how supported do you feel in terms of your health currently? Want from /hopes for healthcare - dancers describe their ideal scenario for how they would like to experience healthcare Expectations - what dancers expect when they are seeking healthcare
Other - odds and ends that I wanted to remember Reference – logistical details that aid in the re-storying in chapter 4
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Treatment / Rehabilitation - stories about receiving treatment or going through a rehabilitation process Dance-specific medicine - when dance-specific practitioners or clinics are mentioned Diagnosis - stories about the diagnosis process Community health services - when dancers utilize community clinics outside of their primary healthcare physician or general practitioner Mental health - stories of seeking help for, or struggling with, mental health Alternative and Complementary Practices: includes all mentions of “Eastern Medicine”, “Holistic health” and “Somatic practices” such as yoga, Pilates, Feldenkrais, and Alexander technique General health (non-dance related) - stories of conditions that would not be defined as musculoskeletal Self-care / prevention - stories that involved the dancer caring for their own health or injuries or steps they took for preventative medicine
Communication with medical professionals - stories of dancers communicating with healthcare professionals Network - lists of the types of practitioners that dancers seek help from or that are covered under their insurance plan Seeking care - stories of dancers seeking care for an injury, mental health, or a general medical condition Financial / Money related - when dancers mention cost or income
Pregnancy / Children - stories of being pregnant or a mother while dancing Retirement / Second career - stories of shifting from professional dance to a second career off-stage
Positive practitioner comments - stories shared that was a positive review of a practitioner in their past Facilitative factors - elements of a dancers life that afforded them access to health insurance or healthcare 281
Being resourceful - describing a hustle to obtain healthcare services
Insurance - any mention of insurance “health cover” “health policy” Private health coverage (Aus) - australian dancers mentioning private health cover
Public health coverage (Aus) - australian dancers mentioning public health cover
Uninsured moment - any dancer speaking about lacking health cover, past or present
ACA specific - american dancers speaking about the Affordable Care Act or
“Obamacare”
Gaining insurance story - stories of how dancers “got on” an insurance policy
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Appendix G: Tables and Figures
Figure 2
Current Expenditure on Health, Per Capita, US dollar
12000
10000
8000
6000 Australia 4000 United States
2000
0
2000 2002 2004 2006 2008 2010 2012 2014 2016
Figure 3
Results of Professional Dancer Self-Identifying Question (Pre-interview survey)
Money Trained Time Priority American Record of Performance Australian Main body Consider
0 2 4 6 8 10
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Table 2
Comparison Elements Between the United States and Australia
GDP - Per Life Total Health External Debt
Population Capita (PPP) Expectancy Expenditure (2016 est)
Country (2017) (2017) (2017) (% of GDP)
United
States 326,625,791 $59,500 80 17.2% 17.9 trillion
Australia 23,232,413 $49,900 82.3 9.6% 1.6 trillion
(Central Intelligence Agency, 2018; Organisation for Economic Co-operation and Development, 2018)
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