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Using Evernote for Continuous Professional Development – a view from General Practice in UK

10 Dec

Like many professional people doctors must keep track of a lot of information. From beginning of December 2012, all GMC registered doctors must engage with 5 yearly revalidation cycle.  Annual appraisal has been in place since 2004 after the Shipman scandal and its aftermath, the legal requirement for revalidation has only now been enacted.

Many different systems are available to doctors to choose from for keeping track of the required documents and learning. The Royal Medical Colleges have systems for their members (e.g. RCGP ePortfolio), the NHS has encouraged a toolkit, and some household names in medical press (eg GP, BMJ eLearning) have also jumped on the bandwagon.

However, after trying out several I have purchased the premium version of Evernote.  Evernote suits my style of learning and integrates easily with all the devices used for work and play – Windows Home PC, laptop and work PC, and android phone & tablet.  It will also work happily on iOS devices and Apple computers.

It has taken some time to get used to the powerful features of Evernote.  The Premium version allows full control of privacy settings which is clearly important for something as sensitive as professional portfolio.  Also the paid version allows up to 1GB data uploaded per month which is generous unless you are in habit of uploading videos or audio files of meetings. This data plan can be increased for another fee.  Acrobat PDF files can be read inside the programme too.  Numerous third party applications are available to expand the capability of Evernote: some are free, many are enterprise (fee paying) solutions.

I have two main folders for notebooks – Personal and Work.  One notebook is publicly shared with my patients – the link is here
My appraisal notebook can be shared with my appraiser for the current year.

Evernote provides a tool to archive twitter posts which is a boon when engaging in professional twitter chats (when you see @myEN the author is archiving post to her or his evernote notebook.  You can add an extension to Chrome or Firefox to help grab web pages or parts thereof and store in  Evernote.

Furthermore, careful use of tags will help with finding notes quickly, though Evernote does a good job with free text searching too.

Finally, the best is kept until last  – automatic adding of useful emails or social network interactions or cloud storage files. The means to do this is provided by a couple of providers which I have stumbled on.  Zapier ( offers free packages for a limited number of “recipes” (5) and ifttt ( offer free packages for unlimited number of “recipes” .  Careful planning can give excellent results for busy doctors (and others).  The instructions for use are straightforward.

After nearly one year nearly 7000 notes have been collected. While not a complete and comprehensive collection of learning and interaction that some may aspire to, it is a good reflection of continuous professional development.

Samuel Shem, 34 Years After ‘The House of God’ – Atlantic Mobile

28 Nov A fabulous essay celebrating humanity in healthcare which must be preserved for all our sakes

Dying with dignity – Liverpool Care Pathway and Palliative Care 2012

11 Nov

With the furore over Liverpool Care Pathway showing little sign of going away it may be a good time to pull together some of the threads. Margaret McCartney has written about the issue in this week’s BMJ (

We need to go back to Dame Cicely Saunders who established the groundwork for the specialty of Palliative Care to understand how we arrived at the stage now:

She founded St. Christopher’s Hospice in 1967 as the first research and teaching hospice linked with clinical care, pioneering the field of palliative medicine.

I was a medical student in the 80’s at Monash University, Melbourne. An element of the curriculum included palliative care, especially pain management. We even has a pocketbook to help with prescription of analgesia. Even so, people were still suffering with pain, sometimes horrible pain, right up to death on the wards. The interns and other doctors in training feared giving too much morphine to our patients. The nurses hovered like hawks to ensure we never over-stepped the mark with pain relief. Patient-controlled analgesia was introduced onto surgical and medical wards to improve pain management with variable success (e.g. Macintyre, 2001).

So fast forward to the Liverpool Care Pathway or LCP

The LCP affirms the vision of transferring the model of excellence for care of the dying from hospice care into other healthcare settings.  We have demonstrated a process that inspires, motivates and truly empowers the generic workforce in caring for the patient and their family in the last hours or days of life.”
Deborah Murphy, National Lead Nurse-LCP, Associate Director MCPCIL

A detail of the process is here

So we get to the recent storm.

Daily Mail 13th Oct 2012

Did NHS kill my mother to free bed? The profoundly disturbing story by son of patient at controversial terminal illness care home
Peter Tulloch believes doctors sought to hasten his mother’s death

He was informed that mother Jean Tulloch had just weeks to live

Without his knowledge, doctors removed her drip but Mr Tulloch believes she was still aware of her surroundings

Daily Mail 14th Oct 2012

Care? No, this is a pathway to killing people that doctors deem worthless

But, as Margaret McCartney discovered, the Daily Mail was a fan only last year of end of live care that worked:

Daily Mail 30 Aug 2011

I’ll always be grateful to the GP who eased Mum’s pain – even if it hastened her death

This was after an example of poor nursing care at end of life was reported in 2009 in the same paper

Daily Mail 28 Aug 2009

Many NHS nurses are still the finest in the world. But they let my poor father die in agony like a dog

We were treated to a celebration of the care UK citizens receive at the end of life in 2010.

Daily Mail 15 Jul 2010

The country tops the Quality of Death Index, which ranked 40 countries according to the care offered to dying people. In second place was Australia, followed by New Zealand, Ireland, Belgium and Austria.

It cannot be emphasised enough that the model of care exemplified by LCP helps reduce, if not eliminate, the disasters highlighted in the 2009 article. The knowledge, skills and attitudes which the LCP training gives healthcare professionals has virtually eliminated the scenes I witnessed as a medical student in the 80’s.

Now we come to the present again. The Association of Palliative Medicine will review end of life procedures

Daily Mail 24 Oct 2012 and here

the Association of Palliative Medicine has ordered a review of the concerns expressed by countless bereaved relatives, with a promise to explore ways of improving practice.

And the new Health Minister, Jeremy Hunt, has chipped in. (Surely not to gain political points)

Huffington Post UK 3 Nov 2012

NHS Constitution: Families To Get Consultation On ‘Death Pathway’ Decision, Says Jeremy Hunt

But wait! Is there anything actually wrong with the LCP?

Christian Medical Comment 16 Oct 2012

Consensus Statement: Liverpool Care Pathway for the Dying Patient (LCP) 

Published misconceptions and often inaccurate information about the Liverpool Care 
Pathway risk detracting from the substantial benefits it can bring to people who are dying and to their families. In response to this we are publishing this consensus statement to provide clarity about what the Liverpool Care Pathway is – and what it is not. 

Read full statement

The Catholic press also expresses view that nothing is wrong with the system two years ago.

Catholic Herald 23 Apr 2010

A dependable pathway to the life beyond

It is important that death and dying in our community is being debated. With the erosion of spirituality in our lives, our mortality is denied. However, it is so sad that some of the most vulnerable amongst us are being used to sell newspapers and gain political points.
Death and dying is part and parcel of excellent healthcare. The healthcare professionals who work in the NHS (and in private sector) understand this. It is a sign of the times that the authority of healthcare professionals (and priests) at the end of life are being called into question. We are the people who witness more death and dying in civilian populations not at war than any other group in our society. General practitioners with their teams are the midwives to dying process and the grief which follows for those left behind.

To give you an idea of the scope of knowledge and skills involved a selection books has been added.

Helpful Palliative Care resources for healthcare professionals


Oxford Textbook of Palliative Care for Children

Paediatric Palliative Medicine (Oxford Specialist Handbooks in Paediatrics)


Oxford Textbook of Palliative Medicine

Oxford Handbook of Palliative Care (Oxford Medical Handbooks)

Palliative Care Nursing, Third Edition: Quality Care to the End of Life

Geriatric Palliative Care

Journals & websites

American Journal of Hospice and Palliative Medicine

Journal of Palliative Care & Medicine

International Association for Hospice & Palliative Care

General and popular books

A selection of books at

EXCLUSIVE: Secret Tory steering committee working overtime to ready NHS for mass privatisation

11 Nov

Sadly what surprises me about this news is that no-one has spotted such a working party earlier, say at the start of the NHS in 1948.

The Slog

Enquiries by The Slog in the later hours of yesterday evening confirmed that an informal but extremely powerful Working Group has been set up by the Coalition – separate from both NHS management and the Department for Health – to assess the best way to facilitate the handover of NHS Hospital Trusts to the private sector.

Although details are hazy as yet, a picture is emerging of a Group very obviously dominated by privateers and anti-State lobbyists. To the best of my knowledge thus far, not a single member of it is closely associated with (or technically proficient in the understanding of) Britain’s rapidly expanding mutuality sector.

In the midst of blanket 24/7 coverage of paedophiles under every care home bed alongside easily the most boring Presidential election since 1972, this NHS story may not gain much traction immediately; but it is nevertheless the clearest sign yet to emerge of…

View original post 700 more words

Never miss another message or blog again?

18 Oct

Today I discover an answer to a prayer. A few weeks ago IFTTT (If this then that) service (at lost access to Twitter. The little tool was a life line for me to keep track of all my tweets which were automatically archived in an Evernote notebook. I discussed Evernote in a recent post so will not elaborate further here.

Anyway, with a new project starting it was necessary to find an alternative. Zapier is a competitor to ifttt which I have never heard of. However, it seems to be more flexible than with corporate options. For my purposes, the free version is sufficient.

I am writing this note as much for my benefit as yours. Why not give Zapier a try. The “zaps” you can make are nearly infinite, just use your imagination. There is no limit to number of triggers on the free plan. There is a time limit; updates will only be sent every 5 hours. If you need quicker polling than this the next tier US$15/mo.


Calibre ebook management & Dropbox

23 Sep


Today was a day of discovery. A discovery which looks to help with book management using the popular Calibre e-book management tool ( and file management across several (mobile) devices and the popular cloud service Dropbox ( ). I can now integrate these with my favourite ebook reader on Android, Aldiko ( )

Introducing dropsync ( which seems to be the answer to the prayers of many people trying to keep their cloud storage synchronised with their laptop, desktop and any other mobile devices. An amazing thing about this – it is Android only at the moment! For an extra £3.99 you can unlock the full functionality of this tool ( ).

Anyone who uses an ebook reader like the Kindle and Kobo should have Calibre on their desktop. Using dropbox on the desktop with dropsync permits 2 way real-time synchronisation with your work at home, work and on your mobile device. You have full control over the folders you wish to manage in this way.

For my ebooks, this provides a very efficient way of keeping your ebook readers synchronised (be warned this will use a lot of data on your mobile plan, so you should only sync on WiFi unless you are on an unlimited data plan. If you are like me the tablet is not always available, so it can be helpful to have the document (book) updated automatically on the phone. For aldiko, the books are saved to /sdcard/eBooks so this is the folder which is synchronised on Dropbox.

Keeping working documents synchronised is also straightforward with dropsync.

Calibre companion ( ) is a paid app (£1.99) which efficiently keeps your ebook library on your mobile device(s) up to date with your main Calibre ebook library. Just wirelessly connect the mobile device with your PC, tell Calibre companion where to store your ebooks (I chose the Aldiko ebook directory).

So one great program for Mac or Android to exploit cloud storage (dropbox), with two fabulous programs for android only at the moment to go further with real time synchronisation of any files/folders (Dropsync) and ebook management on your mobile devices (Calibre companion).

QR Codes

Calibre book management (Windows/android/Mac/Linux) (free)
Calibre companion (android) (£1.99)
Dropbox (android) (free)
Dropbox (windows) (free)
Dropbox (Mac) (free)
Dropsync (android) (free)
Dropsync Pro Key(android) (£3.99)
Aldiko ebook reader(android) (free) ($2.99 [in 2010])

What does MobiMOOC 2012 offer me?

8 Sep

The gauntlet has been thrown.  MobiMOOC 2012 starts this weekend.

Two essays have me thinking – “what does MobiMOOC 2012 offer me?”; “why have I signed up for this activity?”

Michael and Rebecca have written well on their hopes and objectives.  So why shouldn’t I do so too?

Why am I signed up for MobiMOOC 2012?

The simple answer is the 2011-2012 annual appraisal concluded with my Appraiser advising I should be more active sharing what I do and know about eLearning technology and resources with my colleagues.

This sounded easy, but how do you go about demonstrating competence in an area which remains poorly defined, at least in medical education.  Yes, I use android tablet and phone. Yes, I use the cloud to share resources with my students and colleagues. However, this seems trivial when reading all about the activities of many of the facilitators and students in this year’s MobiMOOC 2012.

MobiMOOC 2012 notice turned up on Google Plus I thought this is what I think I need to gain sufficient skills, knowledge and understanding to encourage my colleagues and students to explore the education technologies available to improve the effectiveness and efficiency of their continuing professional development.

What does MobiMOOC 2012 offer me?

Well the simple answer for what is offered is contained in the introduction from Inge

There is a wealth of information and applications and contacts.  But this is worth nothing if I do not implement some of the learning points and engage with my colleagues and students to attempt to persuade more to invest some time and effort into using education technology.

So this gets me to the heart of the matter.  How do you overcome the reluctance of peers to embrace new technology to improve patient care?  Actually, is there evidence that eLearning does improve patient outcomes?  How much additional effort is needed to learn the new tools? What sort of investment?  What is the best device? Why are some patient settings so difficult to work with to improve point of care education and decision tools?

There are probably many more questions. And I hope that the discussions over the coming weeks and beyond will help me overcome the pain points which obstruct progress in the uptake of elearning tools in healthcare.


The Great Tory NHS TUPE Pension Scam: read, share and fight!

25 Jul

Ha! Rid the millstone of NHS pensions to make privatisation a tastier option. Cannot be good for future of the service


I like patterns. They tell you a lot. And I’m generally good at spotting them – on psychometric tests various employers have put me through, one part I usually get maximum marks at is pattern-identification. Sometimes you look at a particular puzzle and it doesn’t seem to make any sense, and then all of a sudden one part will become meaningful and the rest falls into place.

I had a similar experience earlier this week when I saw a comment on Twitter by a friend of mine (@michaelh14 – I’d recommend following him). He was having a discussion with someone and mentioned that if NHS staff are transferred to a private provider their pension rights will be protected by TUPE but new employees taken on by the private employer would not be – and suddenly a lot of pieces started to fit. And they show that this government is making…

View original post 1,737 more words


skwalker1964 | This site is the bee’s knees

9 Jul

GPs are Fantastic Resource

17 Jun

Matthew Parris has managed to stir up debate about UK General Practice. Was this the intention? Was he being deliberately ironic? The timing of his opinion piece on the weekend before the first doctors’ strike since 1975 cannot be a coincidence.

The article can be found here, behind The Times paywall However, in the interest of openness, I have made a copy for you here

If family doctors had not existed, would we today have found it necessary to invent them?

The second question by Mr Parris is arguably the crux of his essay. The short answer is a resounding “Yes!” I will set aside the false premise that the doctors strike, in Mr Parris’ eyes is solely a GP strike. Perhaps because the bulk of the UK public who seek healthcare on a given day normally see GPs one can excuse this falsehood. All doctors (well, > 70%) will not be doing routine tasks on Thursday 21st June.

So back to the invention of family doctors. Family doctors are the descendents of “apothecaries” and “ship’s suregeons”. The health care professional who was available to the masses for many centuries. The idea that specialists should be available to all is a modern concept, especially in the UK where health care delivered by the National Health Service since 1948 is free at the point of delivery.

You do not need to go too far back in time to see that specialist medical advice was only available to the rich – the ruling classes and merchant class. The medical workforce was concentrated in cities, especially London and Edinburgh (and Dublin). Oxford and Cambridge Universities were for a long time the only recognised centres for training physicians in the UK.

The Public needs medical women and men who are trained in the nuances of first contact healthcare. There is far more to the intitial consultation than simply making a diagnosis of a somatic process. Mr Parris is lucky to need a doctor so rarely. His experience does not, in my opinion, give him the right to pass judgement on what doctors like me do!

Barbara Starfield (1932-2011) wrote some of the best essays on the merits of general practitioners and primary health care. An important conclusion is that mature health care systems must have robust primary health care systems to withstand the constant pressures of medical advances in order to protect citizens from the worst excesses of health seeking behaviour. Economies with strong primary healthcare also spent less on health without compromising outcomes. A selected bibliography in support of this statement is here

Are we investing too much in the citizen’s first port of call, to the detriment of investment in the specialist attention to which, to an increasing degree, surgeries are likely to end up referring the patient?

The next question deserves an explicit answer: “No, Mr Parris, we are not investing too much in the citizen’s first port of call”. If anything, there is too little investment in first contact doctoring because politicians are seduced by the gleaming hospital in their constituency. It is not sexy to spend money on often small and out of the way health centres which are often owned by the doctors. There is no political mileage in giving more money to the hardworking GPs and their staff. We do not spend enough money for your campaign funds. Profits are ploughed back into the practice to maintain services. Unglamourous activities like cervical smears and blood pressure monitoring. There is no obvious soundbite for enhancing the environment 95% citizens visit in any year. Greedy doctors must not be encouraged. On the other hand hospital doctors are gagged – prevented from speaking out because of their contracts. GPs remain independent contractors which is an anathema to the Ruling Class.

Is the work of these expensive and expensively trained men and women best directed to the point at which they’re doing it?

“Yes, Mr Parris”. We are the cheapest healthcare professional available to determine whether the first sneeze is the beginnings of a serious illness or just a virus. Making that decision requires confidence, high level of training, and a feel for pattern failure that almost any other healthcare professional cannot do. Nurses are generally hopeless at detecting pattern failure. Secondary care doctors are trained to investigate; general practitioners are trained to reassure. Certainly, we would love to investigate more given the chance (witness the explosion of near patient testing), but there is little evidence that such behaviour improves outcomes. It may reduce the doctor’s stress levels, but that is not a good reason to inflict tests on patients “just because it seems a good idea”.


“Referral rates” — the proportion of GP consultations that lead to a consultation with a specialist — are rising fast

Whose fault is this, Mr Parris? Media campaigns pandering to the worried well concerning the latest medical scare do not help manage demand for secondary care opinions. Two week rules for suspected cancer, demands for early diagnosis of dementia, advances in cardiovascular and respiratory medicine, better endoscopy techniques, imaging techniques denied to GP access by NHS rules, barriers for experienced GPs which prevent in house treatment, and a culture of defensive medicine engendered by people like Mr Parris who insist on certainty in an uncertain world all conspire to increase referrals. This is not of our doing. This protocol driven medicine is the undoing of decades of responsible use of scarce resources.

Perhaps, if the Royal Family could be persuaded to employ a Royal general practictioner, there would be a sea-change in the respect GPs should receive.

Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results. 

Mr Parris should do better research. Nurse-led primary care does not work! 30 minute appointments, protocol-driven working, limited formulary, lack of experience, deference to a GP when things go awry, and catastrophic errors do not support this blithe assertion. Rhona Knight (2008) points out that it would be backward step. If you cannot read the whole article, you will find it here. Nurses are anxious not to fight GPs for primary care; we must collaborate and play to each other’s strengths. Nurse-led clinics can improve health, for example in secondary prevention of heart disease (see Campbell et al 1998) but this is not the same as nurse led general practice.

Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.

The day this arrives, Mr Parris, will be a very sad day indeed for the healthcare of this once proud Nation. At the one and the same time you express such strident opinion, countries around the globe are struggling to implement primary health care modelled on the very system you seem so intent on dismantling: Quatar, India, Poland, Slovenia, USA to name a few. How can such an erudite fellow as Mr Parris get it so wrong?


It feels good to make this effort to dismantle Mr Parris’ thesis. I do hope it is now clear why General Practice and the GP are a fantastic resource for the UK. By the way, the Royal College of General Practitioners is the guardian of the high standards of practice expected in the UK. Its new building in Euston which opens later in 2012 is a testament to the endurance of primary health care and GPs. GPs are here to stay and we will fight hard to protect the most vulnerable in our society from the excesses of the Ruling Classes who share Mr Parris’ views.

Illusions of Autonomy

Where medical ethics and human behaviour meet, by Dr Philip Berry

Enjoying every second

Cada lugar, cada rincón, cada momento compartido arreglando el mundo entre imprescindibles

The Commonplace Book

blogs on public health, science, books, theology and more