The Doctor s Communication

Handbook 8th Edition Peter Tate

Visit to download the full and correct content document:
https://textbookfull.com/product/the-doctor-s-communication-handbook-8th-edition-pet
er-tate/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Skunked Calpurnia Tate Animal Doctor in Training First

Edition Kelly

https://textbookfull.com/product/skunked-calpurnia-tate-animal-
doctor-in-training-first-edition-kelly/

Barefoot Doctor s Handbook for the Urban Warrior

Wayward Taoist Survival Technique Barefoot Doctor

https://textbookfull.com/product/barefoot-doctor-s-handbook-for-
the-urban-warrior-wayward-taoist-survival-technique-barefoot-
doctor/

Communication in History : Stone Age Symbols to Social

Media 8th Edition Peter Urquhart

https://textbookfull.com/product/communication-in-history-stone-
age-symbols-to-social-media-8th-edition-peter-urquhart/

Great Presence: The Failsafe Method for Confident &

Enthralling Public Speaking & Personal Communication
Barefoot Doctor

https://textbookfull.com/product/great-presence-the-failsafe-
method-for-confident-enthralling-public-speaking-personal-
communication-barefoot-doctor/
Strategic Communication in Business and the Professions
8th Edition Dan O'Hair

https://textbookfull.com/product/strategic-communication-in-
business-and-the-professions-8th-edition-dan-ohair/

Barefoot Doctor’s Handbook for Modern Lovers: The Tao

of Amazing Sex Barefoot Doctor

https://textbookfull.com/product/barefoot-doctors-handbook-for-
modern-lovers-the-tao-of-amazing-sex-barefoot-doctor/

Barefoot Doctor’s Handbook for Heroes: The Tao of Fame

and Fortune Barefoot Doctor

https://textbookfull.com/product/barefoot-doctors-handbook-for-
heroes-the-tao-of-fame-and-fortune-barefoot-doctor/

Communication in Our Lives 8th Edition Julia T. Wood

https://textbookfull.com/product/communication-in-our-lives-8th-
edition-julia-t-wood/

Communication Principles for a Lifetime 8th Edition

Steven A. Beebe

https://textbookfull.com/product/communication-principles-for-a-
lifetime-8th-edition-steven-a-beebe/
THE DOCTOR’S
COMMUNICATION
HANDBOOK
EIGHTH EDITION
THE DOCTOR’S
COMMUNICATION
HANDBOOK
EIGHTH EDITION

Peter Tate
Francesca Frame
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2020 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
International Standard Book Number-13: 978-0-367-19822-0 (Paperback)
978-0-367-19821-3 (Hardback)
This book contains information obtained from authentic and highly regarded sources. While all rea-
sonable efforts have been made to publish reliable data and information, neither the author[s] nor the
publisher can accept any legal responsibility or liability for any errors or omissions that may be made.
The publishers wish to make clear that any views or opinions expressed in this book by individual edi-
tors, authors or contributors are personal to them and do not necessarily reflect the views/opinions
of the publishers. The information or guidance contained in this book is intended for use by medical,
scientific or health-care professionals and is provided strictly as a supplement to the medical or other
professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s
instructions and the appropriate best practice guidelines. Because of the rapid advances in medical sci-
ence, any information or advice on dosages, procedures or diagnoses should be independently verified.
The reader is strongly urged to consult the relevant national drug formulary and the drug companies’
and device or material manufacturers’ printed instructions, and their websites, before administering
or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate
whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is
the sole responsibility of the medical professional to make his or her own professional judgements, so
as to advise and treat patients appropriately. The authors and publishers have also attempted to trace
the copyright holders of all material reproduced in this publication and apologize to copyright hold-
ers if permission to publish in this form has not been obtained. If any copyright material has not been
acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced,
transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying, microfilming, and recording, or in any information stor-
age or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copy-
right.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222
Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that pro-
vides licenses and registration for a variety of users. For organizations that have been granted a photo-
copy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are
used only for identification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Names: Tate, Peter, 1946- author. | Frame, Francesca, author.

Title: The doctor’s communication handbook / Peter Tate and Francesca Frame.
Description: Eighth edition. | London, United Kingdom ; New York : Radcliffe
Publishing Ltd ; CRC Press, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2019011897| ISBN 9780367198213 (hardback) | ISBN
9780367198220 (pbk.) | ISBN 9780429243479 (eBook)
Subjects: | MESH: Physician-Patient Relations | Communication | Patient
Satisfaction | Physician’s Role
Classification: LCC R727.3 | NLM W 62 | DDC 610.69/6--dc23
LC record available at https://lccn.loc.gov/2019011897

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents

Preface to the eighth edition ix

Authors xiii

1 The essence of good doctoring: A personal reflection 1

2 Ideas, concerns and expectations 7
3 How doctors talk to patients and why 13
4 Different types of patients 21
5 Patient-encounter outcomes 29
6 How you feel is as important as what you know 37
7 What you need to achieve in a patient encounter or consultation 51
8 Different methods of consulting 71
9 Complex scenarios 77
10 Wider communication and ethical issues 97
11 Communication as a competence? 111
12 Summary 119

Index 123

vii
Preface to the eighth edition

Why would busy, overworked, stressed and burnt-out doctors want to pick up
this book? Because effective and efficient communication is core to all that we
do. We know that poor communication remains the most common reason for
complaints and litigation against doctors. Good communication is not a time-
expensive luxury, but a way of becoming more time-efficient, of improving our
own satisfaction, and that of our patients. Anything that saves us time and helps
us feel more effective in the current climate has to be a good thing.
In the years since the last edition in 2014, the landscape in the National
Health Service (NHS) has changed hugely for all of us. We are under increasing
pressure from rising patient demand, staff shortages, low morale, insufficient
finances and insufficient resources. High-profile scandals involving system
failures in NHS trusts, and criminal proceedings brought against individual
doctors, have produced a climate of fear and a lack of trust. Defensive practice
is pervasive, and morale is low. Francesca recently spent time with a group of
medical students just about to qualify; while this is always a stressful transition,
this group was uniformly pessimistic and negative about their futures, seeing
themselves as cannon fodder in a broken system, and feeling that nothing they
could do would make a difference. Viewed from this perspective, the future
could look pretty bleak.
A serendipitous conversation over a game of golf between two friends led to
an email dropping into Francesca’s inbox titled, ‘The Doctor’s Communication
Handbook, Eighth Edition’ midway through 2018. What Francesca most loves
about this series is the relevance that it has to her own daily work. This eighth
edition hopes to build on that foundation, and to be relevant and useful to both
doctors in training and those who are fully qualified; to be useful both to those
developing their consultation styles and those who think they feel comfortable with
their own established style. There is always scope to improve our communication,
even for those who are experienced.
There is some debate about whether these communication skills are intended
for primary or secondary care doctors. In our opinion this distinction is
meaningless. We are all doctors who are all seeing patients. General practitioner

ix
x Preface to the eighth edition

(GP) practices are evolving rapidly and can now vary hugely, from traditional
practices looking after small populations, to much larger at-scale organisations
which are almost like hospitals in their own right. So, one GP’s experience can
be as different from another’s as the small-practice GP’s is to an accident and
emergency (A&E) or ward doctor’s experience. The delivery of patient care, and
the diversity of structures in which the doctor-patient consultation takes place,
means that the world is no longer a binary primary-secondary divide, but much
greyer and blurred at the boundaries. We hope that this book can be useful
for all.
Indeed, much patient contact these days is not performed by doctors. Nurses,
nurse practitioners, paramedics, healthcare assistants, physician’s assistants
and allied health professionals are just some of those involved. To try and write
this book to encompass everyone was, we felt, straying too far from our brief.
However, the principles of communicating with patients are the same no matter
what your qualification, and we hope that those who are interested will also find
this book useful.
The seventh edition of this book focussed on the huge impact that the rapidly
changing technological world and access to information have had on the doctor-
patient relationship. Not only has our role as a doctor changed, but patient
behaviour has fundamentally changed, and this has continued apace over the five
years since the seventh edition. We would not consider ourselves technophobes,
but the pace of change is scary, and the rapidly changing style of both general
practice and hospital medicine is concerning. New and innovative methods of
consulting are being encouraged and pushed forwards. Artificial intelligence
programmes to help diagnose and manage medical conditions are emerging with
remarkable speed and being heavily promoted in some circles. While change is
necessary and inevitable, and innovation is to be applauded and encouraged, we
must not lose sight of what is important in medicine: the shared understanding
and goals reached by two individuals who try to understand each other from their
own unique perspectives.
For us, the crux of the problem is this: we know that for many patients,
the ability to come and talk about their health concerns, and be listened to, is
hugely important. The act of effective communication alone has significant,
therapeutic benefits, and we worry what the loss of this may mean for future
patients. Some patients may have their needs met by an electronic transaction,
but many will not.
Despite these challenges, medicine remains a fascinating and rewarding
profession, and our unique opportunity to see into the lives of others and make
a difference is a huge privilege. The two authors have worked together to produce
a modern, up-to-the-minute view of the medical conversation. Peter is now
retired from active practice, but for over 40 years has been studying, teaching,
writing for and examining doctors who talk to patients. Francesca is a modern,
practicing, caring GP with a day-to-day understanding of what is happening at
the coalface.
 Preface to the eighth edition xi

This book is a guide to help you talk with, understand and share with your
patients, to demonstrate how you can become more efficient and effective in your
consulting, both for yourselves and for your patients. We hope to demonstrate
the vital therapeutic role of good communication. By the end of this book, we
hope you will understand a little more about the patient in front of you, and also
about yourself.
Good reading.

Peter Tate
Francesca Frame
Authors

Dr Peter Tate, MBE FRCGP, qualified as a doctor at Newcastle in 1968. After

spells as a P&O Surgeon and as a trainee in Kentish Town, he was a family doctor
in Abingdon for 30 years. He was an MRCGP examiner from 1981 and was
responsible for the introduction of the video module in 1996; he retired as Chief
Examiner in March 2006. He was awarded the MBE for services to general medical
practice in 2008. He wrote the first edition of The Doctor’s Communication
Handbook in 1993 and is the author of The Other Side of Medicine, a collection of
essays and short stories (2006). He has also published Seasickness; a novel based
on his experiences as a young ship’s surgeon, The Seanachai; an Irish ghost story;
and The Curatage Ghost, a story for grandchildren. He was a co-author of The
Consultation (1983) and The New Consultation (2003) with David Pendleton, Theo
Schofield and Peter Havelock. He has lectured widely on communication issues.
He is now retired and lives with his artist wife Judy, in Poundbury, Dorchester.

Dr Francesca Frame, MRCGP DRCOG DFSRH, went to Cambridge University

in 2000 and studied pre-clinical and clinical medicine at St John’s College.
Qualifying in 2006, she then went on to complete the two-year Foundation
programme in various posts. While enjoying her hospital medicine placements,
to her surprise, it was the general practice placement to which she felt most drawn,
an interest that led to a place on the GP Vocational Training Scheme. Six years
later, after two children and training part-time, Francesca took a salaried post in
a small, rural, traditional practice in Cambridgeshire. She has now been at this
practice for five years and is due to become a partner shortly.
Francesca is currently an elected member of her Local Medical Committee
and also facilitates small-group sessions for the University of Cambridge Clinical
School, exploring the challenges of modern medicine with students at the very
beginning of their careers.

xiii
 1
The essence of good
doctoring: A personal reflection

The patient will never care how much you know until they know how much you care.

Terry Canale (Tongue et al., 2005)

PETER’S THOUGHTS ON HIS MEDICAL CAREER

How should we distil the essence of good doctoring? What are the precious
formulae that we would want to preserve and pass on to the next generation? Has
the essence changed much over the years? I can help you there.
I can tell you about my father who was a GP in South Shields, on the Tyne.
He was already there when Aneurin Bevin imposed the NHS on an extremely
unwilling profession in 1948. He hated the NHS all his life, perceiving it as
patronising, Stalinist and restrictive. He did love his patients, and was lucky to
love his job. I say ‘lucky’ because the job was perhaps even more all-pervasive than
it is today. As a single hander, as most were, the 24-hour commitment was real,
locums were scarce and expensive, and deputising was unheard of. His surgery
was in a basement in Beach Road, with peeling wallpaper, a smell of damp, and
‘The Monarch of the Glen’ on the wall. My mother was the receptionist, nurse,
dragon and saint at the gate. There were no appointment systems, no team
meetings, no special clinics, no computers, and to be honest no notes worth the
candle. There was a lot of work. ‘The surgery’ started at 8.15 a.m., and ended 40
or so patients later at around 11 a.m. There were then 10-plus visits and another
‘surgery’ between 4 and 7 p.m., often with a couple more visits on the way home,
and most evenings disturbed by more phone calls and other visits. Telephone
advice was not considered quite proper then.
The work was unfiltered, haphazard and very popular – sick notes, ear
syringing, boil lancing, home births, general advice, drastic pharmacology such
as barbiturates, amphetamines, methyldopa, personally mixed placebos, and the
green, red and black bottle.

1
2 The essence of good doctoring: A personal reflection

My father kept going until 1975, and died suddenly of a mixture of heart
disease, a very unhealthy lifestyle and myasthenia gravis. He was 58 years old
and still single-handed.
I came up from the south to help my mother to clear out his surgery. The old
microscope, the pestle and mortar, the empty gin bottles, and about five years of
British Medical Journal issues, still in their brown wrappers, were piled up on the
examination couch. Dad’s desk was a big one, and the patient’s chair was tatty and
rickety, placed directly in front.
His funeral at the local crematorium was attended by a larger crowd than the
average Sunderland Association Football Club match. So many people I didn’t
know came up to embrace me (a rare thing for Geordies) and said how much they
loved him, but one man stands out in my mind. He sought me out as the crowd
was dispersing. He held my hand and looked at me hard.
‘Peter, isn’t it? And you a doctor, too. Not as good as him, though. Your dad,
he was special. He used to listen to you. Didn’t examine you much’. I had worked
that one out. ‘But he listened, and he knew. He always knew, never wrong, because
he always listened he always knew what mattered’.
This concept of ‘mattering’ was new to me then, and it would have been good to
talk to my Dad about it. It was only a year later, after two episodes of collapse – one
while I was consulting, when my first pacemaker wire pierced the right ventricle and
metronomically paced my intercostal muscles – that the concept became clearer.
Lying in the old Radcliffe Infirmary the fear slowly passed, to be replaced by an
angry emptiness. Nobody wanted to talk to me, no explanations were forthcoming.
Perhaps it was because I was a doctor, but from watching and discussing with other
patients the widespread lack of meaningful communication was plain to see.
I had qualified from Newcastle in 1968 and then run away to sea and spent
a couple of years as a senior surgeon with P&O. This was old-fashioned general
practice – no continuity, though – but you did whatever needed doing. Great stuff.
In 1972, I became a trainee in Kentish Town with John Horder and Mike Modell.
A slightly different breed from my father, they were more overtly academic,
less steeped in the day-to-day and more visionary. They were members of the
Royal College of General Practitioners and – most different of all – worked in a
group, a health centre, almost a polyclinic. Here, there were professionals I had
never encountered before, such as health visitors, social workers, mental health
officers, community psychiatrists, practice nurses and practice managers, and
there were wonderful things like night rotas and embryonic deputising systems.
My overwhelming memory of that time is enthusiasm for general practice.
I took a partnership in Abingdon-on-Thames in 1973 and lasted 30 years
there, until the coronary arteries malfunctioned. I was promoted beyond
the level of my own competence in 1978 to be the Oxford District GP course
organiser. I did not really know what I knew and was not yet entirely clear what
the secret of good doctoring really was; I was aware that it had something to do
with communication. Then I met David Pendleton, a young evangelistic social
psychologist, who had come to Oxford to seek answers about the relationship
between doctors and patients. We became friends, and I took a sabbatical and
went to work with him in the Department of Experimental Psychology. We
 Peter’s thoughts on his medical career 3

had an early Sony black-and-white video camera and we started getting our GP
friends, trainers and course organisers to videotape some consultations, so that
we could analyse them, looking for the substance, the kernel, the essence. David
interviewed the patients before and afterwards, and found that their views of
the consultation were not the same as those of the doctor, and often differed
markedly from them. Misunderstanding was the norm. Theo Schofield, Peter
Havelock, David and I were working closely together by this stage, and we felt
that the consultation between doctor and patient needed to be demystified and
the essential tasks clearly delineated. We did this, and out of attribution theory
(why people do what they do) and the health belief model came ideas, concerns
and expectations (ICE), a mnemonic that has spawned a thousand courses, and
we stated that the real essence of any consultation was for both parties to achieve
as genuine a shared understanding as possible.
This, as you know, is a difficult thing to do.
The Consultation: An Approach to Learning and Teaching was published in
1984. Ten years later, frustrated by the relative lack of progress in persuading
others of the goal of shared understanding, a group of enthusiasts, including
Roger Neighbour, Peter Campion, Lesley Southgate and Steve Field, helped by
the genius of John Foulkes, began to introduce the video examination into the
MRCGP. This was an unashamed attempt to influence the teaching curriculum
to move good consulting up the ladder of importance. In 1994 I wrote the first
edition of this, The Doctor’s Communication Handbook, which was intended to be
a user-friendly manual for the new examination. The video examination has come
and gone, and The Doctor’s Communication Handbook is in its eighth edition and
has a new author, but the goal of a shared understanding remains.
What we learned from the 10-year video experiment was that good consulting
is not a natural gift for most of us. It has to be worked at, it has to be practiced and
it has to be critiqued. What all those thousands of videotapes of young doctors
demonstrated most clearly was the very special relationship that patients have
with doctors. As we enter an era of organised discontinuity, we must realise the
main implication of this breakup of the traditional relationship. It means that you
will have to communicate more effectively than me, as you may not get the second
chance that my father and I relied upon.
I will let you in on an embarrassing secret. I like old Westerns. One of my
favourites is John Ford’s Stagecoach (at least I am in good company there, as Orson
Welles is said to have watched it over 100 times before making Citizen Kane). One
of the beguiling aspects of the film is the behaviour of the doctor. We meet him
debt-ridden, fleeing town and hopelessly addicted to whisky. We learn that his
addiction may be related to the unspeakable horrors he has witnessed in the Civil
War, and that he has abandoned all pretence of professionalism and sobriety. He
insinuates himself shamelessly with a mouse of a whisky salesman, and as the
stagecoach rolls along through Indian country he drinks the poor man’s wares.
Then, of course, comes the dramatic twist – the young cavalry officer’s wife goes
into labour at a stage halt, and medical skills, as well as plenty of hot water, are
called for. In one of the subplots the socially despised ‘tart with a heart’ has to act
as midwife to the upper-class lady. The doctor sobers up dramatically with the
4 The essence of good doctoring: A personal reflection

help of plenty of hot coffee, and proceeds to perform the necessary medical duties
through a difficult but successful birth. So far, so clichéd, but good nonetheless.
However, it is the scene after the birth that is most revealing. In the dark semiotic
corridor, the prostitute pours out her problems to the doctor. Should she go away
with the handsome young Ringo (played, of course, by John Wayne)? Should she
tell him ‘the sort of girl she is’? Could the doctor stop him going to a showdown
where he will almost certainly be killed?
The point about these questions and requests that she directs at the newly
rehabilitated doctor is that none of them is remotely medical. He is bemused
but kindly and does his best, but why does she ask him these deeply personal
questions? Of course, it is because she trusts him, and that is because he has just
proved himself, despite all of his past failings, as worthy of that trust.
You are going to be trusted, whether you like it or not. You must consider this,
as it is very important. What British doctors possess, almost uniquely, is a relative
freedom from financial pressures. Our opinions are almost unbiased and our patients
know that. This is something worth fighting for – retaining our patients’ trust.
After 5000 years the role of the doctor has changed. You will be the
interpreters of health-related information. To fulfil this role you will need
knowledge, medical expertise and good organisations, but you will also need
certain internal drivers that will help you to help your patients in an ever-
changing world. You will need to fight to retain your relationships with patients,
where your very presence raises hopes and offers a little magic, and perhaps
the more you are known the more your patients may derive succour from just
knowing you. Therapeutically, you become a very small sea wall between them
and the vast ocean of life.
So, what are these internal drivers that lead us to the very essence of your job?
There are three of them, I think. First and perhaps most important is curiosity –
a desire to discover what really matters to your patient. This leads, second, to a
need to help your patients to understand, which leads, third, to an understanding
of trust. Trust is there, whether you seek it or not, so perhaps it should drive you.
These three drivers were important to my father, and helped me through my own
career, and perhaps they will help you in yours.
Both my father and I qualified from Durham/Newcastle University. My
father knew and told me of the great Geordie paediatrician Sir James Spence,
commemorated at the Royal Victoria Infirmary to this day. His most famous
quotation is as follows:

The real work of a doctor is not an affair of health centres, or

laboratories, or hospital beds. Techniques have their place in
medicine, but they are not medicine. The essential unit of medical
practice is the occasion when, in the intimacy of the consulting room
or sick room, a person who is ill, or believes himself to be ill, seeks
the advice of a doctor whom he trusts. This is a consultation, and all
else in the practice of medicine derives from it.
(Spence 1938)

I have lived my whole career with that quote echoing in my brain.

 Francesca’s thoughts so far 5

FRANCESCA’S THOUGHTS SO FAR

I am at the opposite end of my career to Peter, just having completed five years
post-qualification as a GP, and cannot claim to have anywhere near the level of
experience, or expertise, in the field of communication skills which Peter has
described, and demonstrated so clearly over the eight editions of this brilliant
little book. What I do have is an understanding of the reality of being a doctor
today. It is so easy to forget the underlying purpose of what we are all doing all
of the time.
I was a fresh-faced, enthusiastic and somewhat nervous graduate from
Cambridge in 2006, when I embarked on my foundation training and two years
of hospital house jobs, my head full of how to achieve the perfect consultation,
save lives and be the best doctor the world had ever seen. As many juniors find
during those two years, I learnt a lot, and realised I did not know an awful lot
more. I still knew that communication was hugely important, but there were just
so many other things to think about as well. I learnt how to survive as a hospital
junior, both physically (Addenbrooke’s is enormous; running from one end to the
other with a crash bleep and still being useful when you arrive at the unfortunate
patient requires a degree of fitness) but also emotionally. It is easier to think of
‘the liver failure in F4’ than it is to think of the pain of a patient with a family and
a life still unlived who may not make it through. I believe that we develop many
strategies to protect our own emotional health, consciously or unconsciously, and
these strategies can affect our attitudes and approach to our patients. We build up
protective barriers that can impede us more than we realise.
General practice training was inevitably more focussed on communication and
the consultation, but once out the other end of this I was released into the world
as a brand-new GP. As anyone who has made it to the end of training will know,
it can be a little like stepping off the edge of a cliff. The weight of responsibility,
your list of new patients, the want to appear capable, and the paperwork leave little
room for anything else. Part of what I love about general practice is the autonomy,
but it is an isolated existence. I found I settled into my own style of consulting over
the first few years with which I became comfortable. Much of my self-critiquing
of my consultations was focussed on time. The 10-minute appointment has never
been my friend, and I will admit to being talkative, but my patients seemed happy
and therefore so was I.
Picking up the seventh edition of this book last year was an eye-opener.
Thinking about communication skills as a trainee with exams to pass is a
very different ball game to thinking about them as an established clinician,
and self-critiquing my own consultation style purely for the benefit of myself
and my patients. I found that I approached this dissection of the purpose of
the consultation with a very different perspective as a practising clinician with
experience under my belt; for me this was a light-bulb moment. With all the
pressures of modern-day medicine, I had lost clear sight of the vital role of
reaching a genuine, shared understanding in the consultation. As doctors we
have to read a vast quantity of material; The Doctor’s Communication Handbook
is one of the few that actually changed the way that I practice and think. I hope
that you will agree.
6 The essence of good doctoring: A personal reflection

LET US BEGIN
What we hope to do over the next 11 chapters is help you develop your consultation
skills to become an efficient and effective communicator of medical knowledge
and wisdom. The starting point in Chapter 2 is the key, the cornerstone, to
understanding how to refine our skills. ‘We don’t have time for this!’ we hear you
cry, but that is in fact the whole point.
Efficient and effective communication saves time. More than ever, doctors are
working in a resource-poor system; there is not enough time, money or workforce.
We believe this is what makes efficient and effective communication so important
right now, not just for the safety and well-being of our patients, but for us as well.
Good communication is not a luxury, and it does not require money or even
extra time. All you need is a willingness to keep trying and a want to improve.
It does not really matter, as we said in the Preface, what type of doctor you are
or where you work. We feel it is simpler to try to forget our different roles and
reduce ourselves down to our basic elements: a doctor having a conversation with
a patient. With us so far? Then let us begin.

REFERENCE
Tongue JR, Epps HR, Forese LL. Communication skills for patient-centred care:
Research-based, easily learned techniques for medical interviews that benefit
orthopaedic surgeons and their patients. J Bone Joint Surg Am. 2005; 87: 652–8.
 2
Ideas, concerns and
expectations

The White Rabbit put on his spectacles.

‘Where shall I begin, please your Majesty?’
‘Begin at the beginning,’ the King said gravely, ‘and go on till you come to the end:
then stop.’

Alice’s Adventures in Wonderland, 1865

SOME EARLY TRUTHS TO REMEMBER

For those of you at the beginning of your career, here are some fundamental
truths to remember. For those of you further down the path, take a minute to
remind yourself of these and think about how often you take them into account
when you talk to your patients.

●● The patient is a lot more frightened than you are.

●● The patient thinks it is more serious than you do.
●● Illness is frightening but understanding what is going on helps. This
applies both to the patient and to you.
●● Taking a history is a method of controlling what the patient says.

Those first encounters with real people who have come to you for help in the
hospital or the outpatients department are very daunting. We all suffer the anxiety
of being found wanting, of getting it wrong, of being harshly criticised by our
teachers or, worst of all, just looking foolish.
The best way to start is to think ourselves into the role of patient.
After all, this is not too difficult – we have all been ill at some time and we all shall
be again. When people become ill they ask themselves several questions, such as:

7
8 Ideas, concerns and expectations

1. ‘What has happened?’

2. ‘Why has it happened?’
3. ‘Why has it happened to me?’
4. ‘Why now?’
5. ‘What should I do about it?’
6. ‘Should I go to the doctor?’
7. ‘Is it serious?’
8. ‘Can it be treated?’

Think of the last patient you saw. What questions do you think they had asked
themselves? Imagine that last patient was you. What would you be asking yourself?
Let us suppose that the last patient you saw was in surgical outpatients and she was
a 35-year-old woman presenting to the clinic with a nodular goitre. You have taken
her history and found out that she is married with no children. She first noticed a
swelling in her neck about six months ago, she went to her GP three months ago, and
she has waited for the outpatient appointment since her second visit to the GP two
and a half months ago. The GP has stated in his letter that the thyroid function tests
were borderline normal and that there is no family history of thyroid disease. In your
detailed and systematic history taking you have not discovered any symptoms referable
to the thyroid gland, but the patient does seem to be rather anxious. Examination
confirms a moderately enlarged gland with multiple small nodules, everything else is
normal, but the patient seems to be slightly trembly and perhaps sweating more than
you would expect. Now step aside from your history and examination and ask yourself
what she might be thinking and feeling. Now do it again.
Let us just consider some of her possible thoughts and feelings. First, she is certainly
frightened. Hospitals are terrifying places to most people – they are pain and death
boxes with a funny smell. She is also afraid of the staff, especially the doctors, including
you. Doctors are frightening for several reasons, not least their association with the
mysteries of life and death. They also tend to be dominant, powerful figures who
have control over one’s immediate and even long-term future. This patient knows
that many doctors do not say very much, and what they do say can be difficult to
understand. She also knows that doctors usually do not tell the whole truth.
She is also very concerned about herself. She has a lumpy enlargement in her neck,
which to her is cancer until proved otherwise, and she will take a lot of convincing
because her aunt died of cancer of the gullet (oesophagus to you) and she had lumps
in her neck. She remembers that her aunt’s doctors lied to her aunt, and that the
treatment was horrible and ineffective. She has vaguely heard about the thyroid gland
and knows from a friend that one of the treatments is radioactive. This concerns her
because she desperately wants children, she knows time is passing and she fears that a
dose of radioactivity may put paid to her chances forever. She is also afraid of having
an operation because she has never been in hospital and hates the idea of being ‘put to
sleep’. She does not wish to lose control. She also knows from friends, television and
everyday experiences that operations can go wrong, and the neck seems to be a pretty
dodgy place. Her husband produced a bundle of printouts from three websites he had
found on the internet about the thyroid gland. She did not understand much of this
information and could not bring herself to read some of the more alarming bits. She
 Some early truths to remember 9

wishes that her husband was with her but worries that he has not really wanted to
talk about her neck or her coming to the hospital. She wonders if she is now ugly and
unattractive. The bottom line is that she does not want to die.
The above description is only an imaginative guess at some of our patients’
feelings, but how much of this did your history reveal, do you think? Are these
details just added/extras, or is it important to know? Hopefully you feel it is
important, but not everyone would agree. If you do not agree now, we hope we
can change your mind. Read on.
Imagine you recite the findings of your history and examination to your chief.
She listens and asks both you and your patient (let us call her Mrs Arthur) a few
clarifying questions and examines the thyroid gland herself. She excuses herself
to Mrs Arthur and discusses the options with you while the patient listens.

Dr: Multinodular goitre is a difficult clinical area. Probably the best

treatment is nothing if the patient can accept the cosmetic deformity.
The real patient worry is cancer, isn’t that so, Mrs Arthur?
Mrs A: [A little startled, nods in agreement.]
Dr: Cancer isn’t really a problem. The Framingham Study didn’t find
any in a 15-year follow-up of this sort of goitre, but it remains a
theoretical risk, and if you give enough of any thyroid gland to
a pathologist they will find some sort of cancer. We will scan it
anyway. (See cautionary reference below.*)
The issues we have here with Mrs Arthur are possible toxicity and deciding
the best treatment. The GP’s thyroid function tests were borderline high,
and Mrs Arthur’s clinical state is possibly a little suggestive of hyperactivity.
We should repeat the tests and if they are quite high give her treatment
with radioactive iodine. If that is not successful the next step would be an
operation.

Dr [smiles at Mrs Arthur and leaves the room, saying]: My junior colleague
will explain it all to you. Don’t worry, you are in good hands.

* Before continuing, we should mention that this example was used in the first edition
of this book in 1994. This is the recommendation of the British Medical Journal
article on the subject:

Uncertainty about the benefits and harms of immediate treatment for low risk
papillary thyroid carcinoma should spur clinicians to engage patients in shared
decision making. This will ensure treatment is consistent with the evidence
for the subtype of cancer that they have and with their preferences. Some
patients may prefer not to have aggressive treatment of small, low risk thyroid
cancers, especially those patients where the risk clearly outweighs the benefits
of treatment (for example, older patients, patients with other malignancies, or
patients with severe comorbidities). Patients can be reassured that if nodules
later show more aggressive behaviour the evidence suggests no additional
harm from delayed surgical treatment. (Brito et al. 2013, f4706)
10 Ideas, concerns and expectations

How well do you think you would handle this? What would you say about the scan?
What do you think the patient’s feelings would be on her way home? What might she
say to her husband? Would she come back for the 131I treatment? How helpful was
your history in this context? Mrs Arthur will appear again later, so keep her in mind.
Now think about the last time you were ill. If you are always healthy, take a
moment to get into role and imagine waking with a severe sore throat with a lot of
swollen neck glands and feeling pretty ropey. Do you go to the doctor? If so, why?
If not, why not? What did you tell yourself was happening? What was your worst-
case scenario? Did you/would you have anyone to confide in? Did you/would you
share your fears? What questions would you ask yourself?
Let us go through some of your possible questions and answers:

1. What has happened? It’s probably just a virus – Max had it last week.
2. Why has it happened? I’ve been working late, a bit overtired, my resistance is a
bit low.
3. Why has it happened to me? Rotten luck, but I always get these things – Max
sneezed over me.
4. What should I do about it? Dose myself up with soluble aspirin and it should
just go away.
5. Is it serious? No, it will be gone in a few days.

But what happens if your exams are two weeks away or you have a trip to the
United States planned for next week?

1. What has happened? Oh no, maybe it is a streptococcus. I can’t be ill now.

2. What should I do about it? I’d better get some antibiotics just in case. Maybe
take some time off to nip it in the bud. Perhaps some vitamin C might help?
3. Is it serious? This might make me fail my exam. This will ruin my trip.

Now imagine that your partner has glandular fever.

1. What has happened? Oh God, it’s glandular fever.
2. Why has it happened? It’s Max’s fault for kissing me.
3. Why has it happened to me? I had it coming – life has been too good recently.
4. What should I do about it? I’d better see the GP and get the test done to prove it.
5. Is it serious? Yes, this could put me out for the rest of the year. I’ve also read
that it can cause Hodgkin’s disease – oh my God!
These questions and answers can be translated into the trinity of ideas, concerns
and expectations. To continue with the sore throat and glands scenario, consider
what ideas might be going through your head that first morning.

I feel awful. Really, really bad. Too bad for a cold. It must be flu at the very
least. I bet I got it from Max. He was coughing and sneezing all over me
last week. It might be streptococcal, so a trip to the GP for some penicillin
might help. I wonder if there is any on the ward I could have. I shall have
to get some soluble aspirin.
 Some early truths to remember 11

What concerns might be running through your mind?

Help, I hope and pray it’s not glandular fever. If it is, that’s the exams down
the tubes, and it can lead to Hodgkin’s, can’t it? What if it’s worse? I mean
acute leukaemia can start like this. I have been worrying about my immune
system for some time. I haven’t caught HIV from that needlestick in A&E,
have I? No, that’s silly, but it could turn into quinsy like that poor bloke on
the ENT ward last week. His tonsils were so big he couldn’t breathe. If I don’t
get this fixed pretty quickly, next week’s trip to the United States is finito.

What about your expectations?

If I do nothing except dose myself up it will probably go away, but

penicillin is a good idea because it might speed things up, especially with
the trip to the United States coming up. I expect the old GP will just tell
me it’s a virus and I will have to lay it on a bit thick to get the penicillin. He
might do a blood test for glandular fever. Shall I tell him I’m a bit worried
about HIV? No, he will think I’m being silly. I expect he will tell me off for
smoking, too.

Now think about Mrs Arthur again and consider what sorts of things were going
through her mind before she went to her GP for the first time. What she did
not do was go to them with a nodular goitre. She went because she had certain
ideas about the lumpy swelling in her neck. She had several concerns and a few
hazy expectations.
Nobody goes to a doctor with just a symptom. They go with ideas about the
symptom, with concerns about the symptom and with expectations related to the
symptom. Even in this modern age of endless quantities of information at our

Triptych: Ideas, concerns and expectations. (By Peter Tate [mixed media].)
12 Ideas, concerns and expectations

fingertips, and patients with much more detailed ideas, concerns and expectations,
the principle is unchanged.

REFERENCE
Brito JP et al. Thyroid cancer: Zealous imaging has increased detection and
treatment of low risk tumours. BMJ. 2013;347:f4706.
 3
How doctors talk to patients
and why

The two words ‘information’ and ‘communication’ are often used interchangeably,
but they signify quite different things. Information is giving out; communication is
getting through.

Sydney J. Harris

●● Asking questions only gets you answers.

●● It is not whether the communication between doctor and patient is
good or bad that matters, it is whether it is more or less effective.

For over 5000 years now, the basic style of doctoring can be described in the modern
ethical jargon as beneficent paternalism. The medical profession has thus adopted
a well-meaning parental role in most patient encounters. Doctors have acted on
behalf of, and for the good of, their patients. They have also wielded power over
them. This role, which is taken for granted by our society, produces recognisable
patterns of behaviour, which are disease-orientated with a strong tendency towards
authoritarianism. This behaviour affords the doctor some emotional protection –
in fact often more perceived than real – and is one of the most important reasons
why many doctors find a more sharing approach so difficult.

AGENDAS
One approach to thinking about the ways in which doctors communicate is
to consider the agendas for both doctor and patient. Figure 3.1 demonstrates
diagrammatically the possible spectrum of doctor communication behaviour
with patients.
The right-hand side of the graph is nearly all doctors’ agendas, with only the
presenting complaint coming from the patient. As the doctor’s style moves to the
left, more and more of the patient’s agenda is taken on board, until at the left-hand

13
14 How doctors talk to patients and why

Patient’s agenda Presenting

problems

Beliefs
Hopes
Fears Secondary problems
Hidden problems Perceived problems
Expectations Perceived effects Information gathering
Fact collecting
Analysing
Further questioning
Clarifying
Interpreting
Verifying

Doctor’s agenda
Sharing understanding

Patient-centred Doctor-centred

Figure 3.1 A power-shift model of styles of consultation.

end of the graph it is nearly all the patient’s agenda. Most hospital doctors and still
the majority of GPs tend towards the right-hand end of this model. This is not too
surprising, as it is the way we are taught and for many UK GPs, frighteningly, the
way they are currently paid. The QOF (Quality and Outcomes Framework, the
annual payment and incentive programme for GPs) has been criticised by some
for engendering a ‘tick-box’ way of working, with GPs financially incentivised to
investigate, prescribe or manage according to the QOF criteria, with little room
for the patient’s agenda. QOF ended in Scotland in April 2017, and has been hugely
pared back in Wales in 2018/2019. In England, a QOF review has been undertaken,
but the future is still unknown at the time of writing.
The whole act of taking a history is doctor centred, and it is not necessarily bad
in itself. Medical thoroughness and good pattern recognition are a hallmark of this
style when practiced well. As an example of doctor-centred behaviour, imagine
Mrs Arthur’s first outpatient appointment. It could go something like this:

Dr: Good morning, Mrs Arthur. Your GP says you seem to have a
problem with your thyroid gland. Tell me, have you lost weight?
Mrs A: No.
Dr: Any hot flushes?
Mrs A: No.
Dr: Feeling tired or slowed up?
Another random document with
no related content on Scribd:
 *** END OF THE PROJECT GUTENBERG EBOOK THE
STEREOSCOPE ***

Updated editions will replace the previous one—the old editions

will be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright
in these works, so the Foundation (and you!) can copy and
distribute it in the United States without permission and without
paying copyright royalties. Special rules, set forth in the General
Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree to
abide by all the terms of this agreement, you must cease using
and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project
Gutenberg™ works in compliance with the terms of this
agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms
of this agreement by keeping this work in the same format with
its attached full Project Gutenberg™ License when you share it
without charge with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project

Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United

States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it
away or re-use it under the terms of the Project Gutenberg
License included with this eBook or online at
www.gutenberg.org. If you are not located in the United
States, you will have to check the laws of the country where
you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
containing a part of this work or any other work associated with
Project Gutenberg™.
 1.E.5. Do not copy, display, perform, distribute or redistribute
this electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1
with active links or immediate access to the full terms of the
Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if
you provide access to or distribute copies of a Project
Gutenberg™ work in a format other than “Plain Vanilla ASCII” or
other format used in the official version posted on the official
Project Gutenberg™ website (www.gutenberg.org), you must, at
no additional cost, fee or expense to the user, provide a copy, a
means of exporting a copy, or a means of obtaining a copy upon
request, of the work in its original “Plain Vanilla ASCII” or other
form. Any alternate format must include the full Project
Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™
works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or

providing access to or distributing Project Gutenberg™
electronic works provided that:

• You pay a royalty fee of 20% of the gross profits you derive from
the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
 about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt that
s/he does not agree to the terms of the full Project Gutenberg™
License. You must require such a user to return or destroy all
copies of the works possessed in a physical medium and
discontinue all use of and all access to other copies of Project
Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project

Gutenberg™ electronic work or group of works on different
terms than are set forth in this agreement, you must obtain
permission in writing from the Project Gutenberg Literary
Archive Foundation, the manager of the Project Gutenberg™
trademark. Contact the Foundation as set forth in Section 3
below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on,
transcribe and proofread works not protected by U.S. copyright
law in creating the Project Gutenberg™ collection. Despite
these efforts, Project Gutenberg™ electronic works, and the
medium on which they may be stored, may contain “Defects,”
such as, but not limited to, incomplete, inaccurate or corrupt
data, transcription errors, a copyright or other intellectual
property infringement, a defective or damaged disk or other
medium, a computer virus, or computer codes that damage or
cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES -

Except for the “Right of Replacement or Refund” described in
paragraph 1.F.3, the Project Gutenberg Literary Archive
Foundation, the owner of the Project Gutenberg™ trademark,
and any other party distributing a Project Gutenberg™ electronic
work under this agreement, disclaim all liability to you for
damages, costs and expenses, including legal fees. YOU
AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE,
STRICT LIABILITY, BREACH OF WARRANTY OR BREACH
OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH
1.F.3. YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER
THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR
ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE
OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF
THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If

you discover a defect in this electronic work within 90 days of
receiving it, you can receive a refund of the money (if any) you
paid for it by sending a written explanation to the person you
received the work from. If you received the work on a physical
medium, you must return the medium with your written
explanation. The person or entity that provided you with the
defective work may elect to provide a replacement copy in lieu
of a refund. If you received the work electronically, the person or
entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund.
If the second copy is also defective, you may demand a refund
in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set

forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’,
WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS
OR IMPLIED, INCLUDING BUT NOT LIMITED TO
WARRANTIES OF MERCHANTABILITY OR FITNESS FOR
ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this
agreement violates the law of the state applicable to this
agreement, the agreement shall be interpreted to make the
maximum disclaimer or limitation permitted by the applicable
state law. The invalidity or unenforceability of any provision of
this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the

Foundation, the trademark owner, any agent or employee of the
Foundation, anyone providing copies of Project Gutenberg™
electronic works in accordance with this agreement, and any
volunteers associated with the production, promotion and
distribution of Project Gutenberg™ electronic works, harmless
from all liability, costs and expenses, including legal fees, that
arise directly or indirectly from any of the following which you do
or cause to occur: (a) distribution of this or any Project
Gutenberg™ work, (b) alteration, modification, or additions or
deletions to any Project Gutenberg™ work, and (c) any Defect
you cause.

Section 2. Information about the Mission of

Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new
computers. It exists because of the efforts of hundreds of
volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project
Gutenberg™’s goals and ensuring that the Project Gutenberg™
collection will remain freely available for generations to come. In
2001, the Project Gutenberg Literary Archive Foundation was
created to provide a secure and permanent future for Project
Gutenberg™ and future generations. To learn more about the
Project Gutenberg Literary Archive Foundation and how your
efforts and donations can help, see Sections 3 and 4 and the
Foundation information page at www.gutenberg.org.

Section 3. Information about the Project

Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a non-
profit 501(c)(3) educational corporation organized under the
laws of the state of Mississippi and granted tax exempt status by
the Internal Revenue Service. The Foundation’s EIN or federal
tax identification number is 64-6221541. Contributions to the
Project Gutenberg Literary Archive Foundation are tax
deductible to the full extent permitted by U.S. federal laws and
your state’s laws.

The Foundation’s business office is located at 809 North 1500

West, Salt Lake City, UT 84116, (801) 596-1887. Email contact
links and up to date contact information can be found at the
Foundation’s website and official page at
www.gutenberg.org/contact

Section 4. Information about Donations to

the Project Gutenberg Literary Archive
Foundation
Project Gutenberg™ depends upon and cannot survive without
widespread public support and donations to carry out its mission
of increasing the number of public domain and licensed works
that can be freely distributed in machine-readable form
accessible by the widest array of equipment including outdated
equipment. Many small donations ($1 to $5,000) are particularly
important to maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws

regulating charities and charitable donations in all 50 states of
the United States. Compliance requirements are not uniform
and it takes a considerable effort, much paperwork and many
fees to meet and keep up with these requirements. We do not
solicit donations in locations where we have not received written
confirmation of compliance. To SEND DONATIONS or
determine the status of compliance for any particular state visit
www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states

where we have not met the solicitation requirements, we know
of no prohibition against accepting unsolicited donations from
donors in such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot

make any statements concerning tax treatment of donations
received from outside the United States. U.S. laws alone swamp
our small staff.

Please check the Project Gutenberg web pages for current

donation methods and addresses. Donations are accepted in a
number of other ways including checks, online payments and
credit card donations. To donate, please visit:
www.gutenberg.org/donate.

Section 5. General Information About Project

Gutenberg™ electronic works
Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could
be freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose
network of volunteer support.

Project Gutenberg™ eBooks are often created from several

printed editions, all of which are confirmed as not protected by
copyright in the U.S. unless a copyright notice is included. Thus,
we do not necessarily keep eBooks in compliance with any
particular paper edition.

Most people start at our website which has the main PG search
facility: www.gutenberg.org.

This website includes information about Project Gutenberg™,

including how to make donations to the Project Gutenberg
Literary Archive Foundation, how to help produce our new
eBooks, and how to subscribe to our email newsletter to hear
about new eBooks.