I read Jason Kottke's blog on a regular basis, probably because he posts a lot of stuff that is just interesting from the standpoint of human communication and analysis. The latest item that caught my eye was this 20 year old letter to the band Nirvana by their prospective sound engineer - Steve Albini. To set the context for this letter, Nirvana had released one of the the highest selling rock albums of all time two years earlier, so at the time this letter was penned the group was huge. There is also a documentary out there about the production of that album with commentary from that sound engineer (Butch Vig) and his analysis of the group and the recording that is very interesting. So the group was huge and they probably had access to the same sound engineer who made the most successful rock album of all time. I looked at my copy of In Utero and confirmed that the band did in fact hire Albini. The hiring and ultimate product was not without controversy and there are 48 references to Albini in the Wiki piece on In Utero, some of them referring back to the original letter. I thought it was a remarkable document about providing service, the parameters of that service and the associated philosophy. I will use a brief excerpt of this letter as an example:
"#2: I do not consider recording and mixing to be unrelated tasks which can be performed by specialists with no continuous involvement. 99 percent of the sound of a record should be established while the basic take is recorded. Your experiences are specific to your records; but in my experience, remixing has never solved any problems that actually existed, only imaginary ones. I do not like remixing other engineer's recordings, and I do not like recording things for someone to remix. I have never been satisfied with either version of that methodology......"
This letter does contain the rough language that you would expect to hear from young men before they recognize the value of language that never needs to be censored, but there are potentially important lessons.
I have had the privilege of talking with people in considerable detail about their medical, psychiatric, social and family histories since about 1978. That is a long time by anybody's standard. There are some things that jump out of those interviews that seem to not change over time. I am always surprised by the implicit rather than explicit agreements between physicians and their patients. That is especially true since managed care companies started dictating the practice parameters of their physician employees on a large scale basis. I wonder if things might be a lot better if the relationship between a doctor and his/her patient was not spelled out as clearly as the letter from this sound engineer. I thought I would compose a parallel letter. It might go something like this .
That is my first attempt to write a letter about what you might expect in seeing me for psychiatric treatment. I intentionally wrote it in a manner similar to Steve Albini when he described what it might be like to employ him as a sound engineer. The whole idea of being very clear with people about what they can expect and how they need to interact with psychiatrists in treatment has never been more critical. For all of my career (so far) I have been an employee of a healthcare organization. In that situation that adds a dimension to the treatment contract. For example, do the organization that employs you have the same priorities and the same approach to patient care? If not, it might be very difficult for you to pen a sample letter like the one I have written. You can't really talk about psychotherapy or even lengthy evaluations if your organization allows you to see patients in 10-20 minute appointments to refill their medications.
I am very interested in hearing what other psychiatrists would add or subtract to what I have so far. I would also be interested in hearing about any existing letters. I think they would also be very useful for psychiatrists starting out of residency or psychiatrists going into private practice after years of working as an employee.
George Dawson, MD, DFAPA
If you send me a letter, with your permission I will scan them into Dropbox and post the links right here with any title that you want me to use including "anonymous":