This is a work in progress.

More highly developed chapters  are marked ** ** in drop-down table of contents and more accurately reflect progress and the direction of future development.


250Textbooks is an open courseware guide to General Medical Practice.

up to date factual content in an attractive usable accessible format
reminders flags and pointers to essential core knowledge from basic sciences and clinical training plus new knowledge one might have missed
oci and context for both the patients complaints and the doctors understanding of the same


basic skills + knowledge + access to advanced skills and knowledgeconfidence efficiency and job satisfaction
Relevant Applied Clinical Sciences
Normal Values to aid assessment
Approach to the patient / History Exam Routines / Communication Tricks / Management
Common and important
Rare but important (Life or Limb Threatening)
Contemporary (including Hot Topics but not swamped by them given everything changes every 5 years)
Interesting – something to browse which complements learning needs otherwise met elsewhere eg exam crammers
Completeness – at least something about everything if only a link


 Organisation of Chapters and Content
RCGP Curriculum  We were initially sceptical about the RCGP Curriculum, having fried our brains trying to decode its various domains and other goobledygook.
We snorted derisoraly at its obvious omissions, and puzzled over its overlooking of a solid clinical bedrock.
However the syllabus did finally offer a consistent enduring framework for where to put stuff and in doing so helped reignited this project.
Natural fit  particularly with respect to Specialities and Organ Systems.
If the advanced/detailed knowledge can fit somewhere and build upon the core understanding than its going to be remembered or accessed more readily – now where did I put that “knowledge” or – where should i put this new factoid
Considerations  1 Works like a book and navigable like a book – cover to cover – or within individual sections – not via scatty attention-divering nested and branching hyperlinks – everything in one place, uncluttered and searchable but also readable like a book without branching hierarchies or scatty attention-diverting chase-the-rabbit links-to-links-to-links – the links are here 5000 of them but there’s always a way back and a context.
Precise navigation not currently so easy in Pressbooks but should improve
2 User Experience (UX)
3 Accessible online or offline including via mobile devices.
4 Open Source Trans-Portable
Why bother?  For students, established practitioners and life-long learners alike,
there is too much to know and not enough time to learn it and it’s all over the place


is this just a collection of links?
We’re working on increasing/improving the content – the aim is to present essential practical  material plus wider stuff plus up to date stuff compactly. But it is an open source textbook stupid.Many resources already exist which cover areas of the curriculum/terrain much better than I or anyone can attempt to precis or convey better.
The age of of a large up-to-date single or multiple author textbook is probably over- we’re genuinely trying to harness the best aspects of a new educational/academic/publishing paradigms whilst respecting the past – standing on the shoulders of giants – not kicking at their heels
Where are the references?
The link is the reference/ attribution dum head but we hope to improve on this without cluttering things too much.References to trials, original papers and other primary sources can be found via links to the original articles, news items, or summaries from NeLM, eCAB or similar. Users can click through to the source and then then use bibliographic tools like Athens or Zotero tools to get/save the citation should they wish.This is first and foremost a handbook vade-mecum whatever but we are aware of the need to reference/cite/attribute/acknowledge sources better particularly if we are arguing for a new academic zeitgeist eg – what will a future essay/Msc/PHD thesis look likePressbooks does allow footnotes and we will look at including these to improve attribution and academic provenance.Why WordPress?
Wordpress offers a free/affordable  stable platform easy to use and accessible from any computer or wifi/3g device anywhere
(offline too though the Wordress App hasn’t worked that well with our large site).
Use of themes, plugins and widgets allows fantastic opportunities for almost effortless customisation with no programming skills. With all the information safe and transportable. Not locked-in to any particular institution or software provider.
In fact we’re now of-course using Pressbooks which is built upon WordPress. There are some current limitations and restrictions  but (like wordpress itself) the platform is continuously improving.
Why you tube?
We can post links from youtube (and other mainstream content sharing/social media sites) simply as links without embedding ie redistributing the content – hopefully side-stepping (in good faith) copyright challenges whilst also keeping open our epub aspirationsIn fact were converting embedded videos to links on the pressbooks site. They dont load so well with each Chapter as a single web page, nor export to epub. We hope to arrive at a best compromise that marries the content of this site with its sister site 250 Textbooks/ Hacking Medicine but how this pans out is dependant on how the technology emerges.
Why 250 textbooks
Clearly writing a (multimedia/multisensory) textbook to solve the problem of information overload is not for everyone.bWe call it a textbook but it’s essentially a database of stuff we think we might need to know to improve clinical practice and professional and patient satisfaction whilst also offering a clear place for any new information or revisions. Memory Experts and Educationalists emphasise the need for loci or places to hook new knowledge onto (the RCGP curriculum offers some help here) and the learning advatages of mult-sensory (metacognitive) stimulation.If I go on say a Management/Teaching/Diabetes course or whatever and cover Maslow or pioglitizone or whatever I know there’s an entry for that already so I can add any new notes to that at 250 textbooks or for less processed material to the linked eportfolio at 250Credits.comThis worked well on the 250 Textbooks / Hacking Medicine WordPress site where every topic was a descrete item/page – hopefully this will work equally well when there is a search facility in Pressbooks.
Lucy Jenkins “things one might have missed whilst blinking”Nevermind blinking when did we fall asleep and miss everything?
too much to know and not enough time to learn itNevermind the noise to signal ratio in a traditional textbook is high – nowadays important medical information is delivered in policy and procedure documents more akin to a business proposition and drier than the driest of textbooks – see also metacognition
Netter and the AAG series
some well meaning attempts to tailor/subjugate knowledge from other areas to a medical education context can lead to a paradoxical and unhelpful divorcing from its real-world sensibility, leading to either oversimplification or worse over-abstraction which may be partly responsible for the resistance to many otherwise useful concepts by die-hard pragmatist “adult-learners”. More skeptical observers might conclude there is a more active conspiracy to over-complicate things to bolster the industry and high-priestdom of medical education. This is not necessarily my viewpoint – our aim is to stand on the shoulders of giants not kick at their heelsChallenging and rewarding as general medical practice is, the clinical isolation, epidemiology of conditions presenting, and their precise clinical and non-clinical emphasis is such that there can be a gradual distancing of primary care conditions from a basic clinical and biological context.Similarly lone working and years of pragmatic short-cutting can lead to an erosion in clinical assessment and communication skills. This may undermine otherwise genuinely astute observations such practitioners may posses based on their years of practice, dealing with thousands of patients, and seeing various fashions come go and come back again.A purely “primary care” emphasis to care sometimes overlooks the fact the patients ailment is ignorant of the context in which it is to surface.Certain conditions may be relatively uncommon in any individual practitioners daily experience – but hospital outpatient clinics, wards and ITUs are full of (patients with) such conditions.its actually quite easy – ahem – history, examination, recording one’s observations remain the key to being a good clinician, helping the patients and having a rewarding career.Complexities intervene but diseases change less often – keeping up with the drugs and new therapies isn’t that hard – your patient with heart failure is no different than the same Osler described the human body hasn’t changed
Does the internet limit or extend the human mind? BMJ 2011


enduring clinical knowledge and skills as the bedrock of successful practice as a doctor
integrating med school foundations with everyday practice and lifelong learning compliant with but not swamped by administrative mores
use of checklists routines prompts and guidelines as reminders and pointers not dictats
inclusion of topics from less traveled roads – hinterland specialities – emergencies and less common diagnoses
management/“leadership” communication and learning/education as generic human skills not contemporary ideas specific or unique to medicine
the facts + the concepts + how to do it well

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