Cancer pain article by international pain experts at Royal Marsden

I asked our medical education director (who is also a senior consultant anaesthetist) and he said the following are international pain experts

  • Paul Farquhar-Smith
  • Matthew Brown
  • John E Williams

Paul Farquhar-Smith and Matthew Brown have just published the special update on persistent cancer pain which includes all the latest updates on different types of cancer pain and treatments pcu-24-4_web


I will continue to put articles as I find them on the cancerpainres twitterfeed for now

Shinseidokan dojo: Toughen up!


We are often told if we have injuries it’s because we’re moving the wrong way which is also frustrating and true. I don’t agree with the classic taller, big, muscles fighter etc – small people like me can build up muscle and get injured at the same time. Which does obviously boil down to practice and moving correctly etc

Course content 1-4 draft 0.1

coursecontent (pdf)

A lot still to do ! If anyone is interested in contributed all of the pages, documents and videos are in the back end site development of People’s Uni, please contact me for a login.

Once upon a time..

Have been thinking about liability scenario as a way of tying up first three sections. This is not going to be it, but if it was a game – it may be along these lines (disclaimer I was once a primary teacher)

You wake up one morning covered in blue spots. You go to your local pharmacist in the village

You: Hey

Pharmacist: Hey

You: You sold me those pills yesterday and now I’ve got blue spots. You didn’t tell me I could get blue spots.

Do you?

a) I’m going to sue your pharmacist ass right off, I have 3 lawyers on speed dial

b) Buy something else to get rid of the blue spots

c) walk away

You choose c) for now because you are in a village and have no idea what speed dial is or where you can find a lawyer. Feeling a little blue, you take yourself off for a nice walk in the countryside. You sit down on the edge of field by some woods and decide you’re hungry. You see a bunch of mushrooms. Do you?

a) Eat one because you think they’re the same ones you saw Matt Baker cook with on Countryfile tv programme last week

b) Don’t eat

c) Eat after checking your field guide to mushrooms pocketbook which of course you have with you at all times.

You choose a) and suddenly after an hour or so you notice most of your blue spots have disappeared. You get up and wander over to your uncle’s house across the field. Your aunt is in and you tell her all about your magical appearing & disappearing blue spots. She says you’re kidding and shows you her blue spots. You both wander back over to the wood and she eats a mushroom. Sure enough her blue spots disappear.

Word starts to spread around the village by evening and before long the mushrooms are all gone, before the pharmacist can get anywhere near them and start grinding them into powder. Nobody seems to mind about the large orange dinosaurs that everyone has seen arriving next to the woods snice they ate the mushrooms.

The next day you find another bunch of mushrooms have grown so you decide to take them to the next village’s market and sell them. Getting a little carried away, you make a big sign saying – mushrooms cure cancer and the next thing you know a stranger has bought the whole bunch and walked away.


Pharma course content sections 1 and 2, first draft

Some links won’t work as they have document or other module links in the course attached to them, but will provide later:


This draft has not been contributed to / reviewed by anyone else yet and as a first draft may be unncessarily boring, but a way of getting ‘words on paper’ which gives others something to work with. I have often noticed in most eLearning development projects I’ve been involved with that even experts in their area are not used to writing content so it’s not until someone writes something that they start to input.

Hope to upload drafts for 3 and 4 by end of tomorrow.


Randomised control trial background briefing paper

Can’t publish the full thing but the cost reduction/reallocations based on previous baseline I created at MHRA a few years ago and use occasionally when needed.

pdf version & below

Consultants Mandatory Training replaced by online learning

We are proposing to replace the face to face training sessions with a full online learning programme, following feedback from consultants during the next 2/3 months. Consultants Mandatory Training is currently delivered as a series of face to face training sessions during a day. The costs for the Trust include the consultant clinical time away from patient care and trainer time for preparation and delivery. The Trust has recently implemented a new learning management system – the Learning Hub which allows greater ease of access to a wider range of online learning including mandatory training modules.

The Learning & Development team have been working with subject matter experts overseen by the PGME Director to develop online learning content suitable for consultants. This means that they can complete the modules during their own time and location because the hub is hosted securely on the internet with a design that allows mobile and computer access.

As humans, consultants face increased information overload and retention issues. Face to face training may address an organisational need at the time but it takes them away from patient care and is not known how they need to use or apply any new knowledge or behaviours back in their work environment. Sometimes there may be a delay in needing to apply any new knowledge or behaviours which mean that retention from the face-face training session will continue to decrease.
The availability of online packages and resources on the hub helps address information retention and accessibility of information as needed including use of a mobile device. It is hoped this evaluation exercise will provide evidence about the effectiveness of learning interventions to meet organisational risks or needs as well as at a personal level.

Feedback indicates that consultants do not wish to spend time in classroom training for mandatory subjects. This analysis identifies areas where time and cost can be saved or reallocated by using eLearning. A consultant will spend approximately ½ day of clinical time attending mandatory training. Completing eLearning packages and/or refresher activities online can be done either outside of clinical time if preferred or approximately ¼ day continuously using the hub.

Baseline Cost Reductions / Reallocations:
Approximate Trainer & Training hours for Consultants Total days
2016 Total Days spent in Mandatory Training (total attendee hrs) x days (x hrs)
2016 Total Days Trainer & Support x days (x hrs)
2016 total days consultation, design, evaluation, admin x days
2016 total days delivery x days
2016 Hours spent in L&D admin support x days
2016 Total attendee, trainer & admin days x days
2016 Days spent in Consultant MT x days
2016 Days Trainer & Support for Consultants MT x days
Avg total trainer & admin Cost £x
Avg total attendee Cost £x
Avg Total Locum Cover Cost £x
Avg Total Cost £x

Evaluation Design
Whilst there is a suggested cost baseline, we do not have a baseline for what is an effective learning intervention as opposed to other interventions to meet the needs of mandatory compliance.

The Trust currently use feedback questionnaires similar to level 1 of the Kirkpatrick model which attempt to gauge effectiveness based on a reaction / satisfaction after the learning intervention1. Additional levels are learning – the extent to which participants change attitudes, improve knowledge or increase skills, behaviour where the new knowledge, skills or attitudes transfer into their job (e.g. through an assessment) or a further course and finally organisational results from the change in learners.2

Critiques of the model suggest that it removes the focus away from instructional design (a core component of online learning packages development), it does not accurately measure whether learners remember anything or whether they are motivated to apply what they’ve learned. This could be true in an online or face-face context.

Other critiques are that it falsely correlates feedback questionnaires with learning results3, or causal links between positive reactions and additional levels assuming that each level of evaluation provides data that is more informative than the last 4, insufficient evidence about how evaluation can inform whether good or bad behaviours which could then affect organisational risks can occur.

So evaluation of mandatory training for consultants could inaccurately identify whether this learning intervention has helped – such as a reduction in HAIs where consultants sit in a face-face session or online learning package to see examples of how to wash hands. You could also bring in clinical case studies where consultants could evaluate the evidence of hand washing in different clinical scenarios but this is also not possible to evaluate whether a more interesting learning intervention in a face-face session or online is effective in meeting a reduction in HAIs.

Effective learning evaluations should help organisations and individuals apply the principle of beneficence – an ethical duty where “actions must be taken when the opportunity arises to actively contribute to the health and welfare of clients and stakeholders”5

There are risks that a Kirkpatrick model will not be able to convey accurate information about whether risks have been addressed to stop future harm or loss6
Applying the principle of beneficence, as learning professionals we are ethically obligated to provide evidence of whether evaluation of a learning intervention is effective. That should extend beyond the organisation so that this exercise can be evaluated by a wider audience.

Alternative evaluation models suggest that a mix of accumulation of evidence over time and qualitative studies would be useful. Whilst is is not possible to have a group of consultants with a placebo (no mandatory training) currently, it is hoped this exercise could inform discussion to see if this is possible for future learning interventions. If we don’t then we are failing in our ethical duty.
A group of consultants who have registered to attend upcoming mandatory training sessions will be randomly selected to complete the training using online learning through the hub. An additional consultant will act as observer during the face to face training sessions.
Qualitative data will be gathered through short interviews and anecdotal snippets provided by..

1. Kirkpatrick, D. L. (2001). Evaluating Training Programs: The Four Levels ,2 ed. San Francisco, CA: Berrett-Koehler
2. Owston, R (2007), Models and Methods for Evaluation, Journal for the Theory of Social Behaviour 1(1):75 – 93 DOI: 10.1111/j.1468-5914.1971.tb00166.x
3. Thalheimer W(2015) Kirkpatrick Model Good or Bad,,
4. Bates R, (2004), A critical analysis of evaluation practice: the Kirkpatrick model
and the principle of beneficence, Evaluation and Program Planning 27 , 341-7
5. Bates R, (2004), A critical analysis of evaluation practice: the Kirkpatrick model
and the principle of beneficence, Evaluation and Program Planning 27 , 341-7
6. Bates R, (2004), A critical analysis of evaluation practice: the Kirkpatrick model
and the principle of beneficence, Evaluation and Program Planning 27 , 341-7
7. Owston, R (2007), Models and Methods for Evaluation, Journal for the Theory of Social Behaviour 1(1):75 – 93 DOI: 10.1111/j.1468-5914.1971.tb00166.x

Randomised control trial attempt – eLearning vs f2f

This won’t be a paper but in summary – groups of consultants attending mandatory / compliance f2f training were randomised with the Postgraduate Medical Education Director selecting anonymised bookings with only the word Chelsea or Sutton visible.

Different training occurs each month depending on need. If an elearning package was available then this was offered to the randomised group for that month.

We have received limited feedback but the feedback received so far has been a strong preference for elearnung so that it fits with clinic scheduling. I wrote a cost benefit analysis to include consultant time and locum cover when required to attend f2f training.

Approval was not granted as yet for a separate placebo group to receive neither f2f or elearning (instead to make their own learning arrangements) but hope this will continue to be in discussion further along. One of the reasons being unable to produce an evaluation that doesn’t disrupt patient care.

It has been a useful exercise.

Blood app link 


Blood app

This will be going in as a little case study/vignette in an apps development section of the Peoples-Uni module. Summary is

The app started life as an idea 7 years ago following a suggestion by a junior doctor during a training session run by a blood transfusion practitioner in her previous Trust. The doctor talked about the need to have guidelines available at the time of need. The idea was proposed to the NHS Blood Service, the nurse partnered with an NHSBT colleague and worked with an internal developer in the NHS Blood service to create a trial app based on platelets guidance.

They completed extensive literature based and other market research to find out what apps clinicians were using, whether they were likely to use an app for this purpose, what would be a good design. The app was successfully tested by clinicians and other research colleagues. They also conducted post-market surveillance.

They have decided to extend the app to include clinical decision support that will affect patient outcomes, which falls in the scope of regulatory approval as a device. The proposal was resubmitted to the NHS Blood service who approved a larger budget, there was a tender for external developers and a more formal clinical evaluation team from multiple Trusts or practices. The partner has managed the regulatory approval approval to date and the nurse has managed the research, the communications between all the clinical professionals as well as the clinical input into the design and development.

They are aware that now the market has been saturated with many apps but due to the clinician buy-in throughout the process they believe they have a product that others will find helpful. The nurse has identified some unrealistic outputs from the algorithm which they are currently intending to fix before releasing the app to the clinical evaluators shortly.

I have offered to help with promoting it. I don’t think a developer would want to hear that their journey has been 7 years but they both have other full-time jobs and complete research so it is not a guideline for how long it could take. It does show that clinician buy-in is stronger if they are involved from the outset.


Cancer pain research twitter feed

Whilst still sorting whether there is going to be a cancer pain app or whatever from ICR, I’ve set up an unofficial twitter account to curate this – over the next few days I will be finding cancer pain researchers in ICR, The Royal Marsden and beyond. It will also include social, psychological research on pain and some patient generated pain toolkits, videos etc

English and global languages

This is featuring again in conversations, probably due to Brexit and the freedom granted by the media to express multiple racist comments (apparently over 150 in reply to a local news story about a new child from Calais being reunited with family).
I don’t agree with the idea /ideology of English being the universal language – and I think it’s in most cases due to the immaturity of computing to date as well as global trade.

It appears to be further evidence of the ossification of UK/US with structures so solidified that it has very little flexibility to adapt.

I have started a Russian language course and although I’d quite like to travel back in time and have words with St Cyril about character case; some of it is quite similar to Turkish and I can say please, thank you, water, fruit, coffee, tea so once I have kick, block, strike and punch 😉

However hard it is for Brits & US citizens to adapt, it is possible by learning other languages and I do believe that a multi lingual world is all for the better. You can’t just reduce a language to one set of words and say this is how it’s going to be, that ignores the sources which make up languages in the first place.

Top Internet languages: 
What the British Library says about English as a global language:

What the Oxford English dictionary has to say about its sources:

Breaking bricks

This winter I will be practising boards and hopefully bricks as it’s something that you can just get on with in your own time and I can do in the garden I share.

At the very first tkd session I ever attended (age 37/8) I chatted to one of the female black belts who had some amazing bruises all the way from her hand to elbow. For their black belt they needed to break boards / bricks and she had been practising but not got it fully figured out.

We do some basic thin board breaking (hand and foot) but it has not yet been a requirement for our black belt testing or a particular type of material. I am interested in practising further though, one of the teenagers at our martial arts summer camp had to break half a brick for his tang soo do test. I chatted with a former bricklayer (not martial artist) and he said not all bricks and concrete would be possible to break. I’m meeting some of our other black belts outside of training later this week so will find out what they are doing and take from there.