BackgroundThere is a strong policy drive towards implementing alternatives to face-to-face consultations in general practice to improve access, efficiency, and cost-effectiveness. These alternatives embrace novel technologies that are assumed to offer potential to improve care.AimTo explore the introduction of one online consultation system (Tele-Doc) and how it shapes working practices.Design and settingMixed methods case study in an inner-city general practice.MethodThe study was conducted through interviews with IT developers, clinicians, and administrative staff, and scrutiny of documents, websites, and demonstrator versions of Tele-Doc, followed by thematic analysis and discourse analysis.ResultsThree interrelated themes were identified: online consultation systems as innovation, managing the ‘messiness’ of general practice consultations, and redistribution of the work of general practice. These themes raise timely questions about what it means to consult in contemporary general practice. Uptake of Tele-Doc by patients was low. Much of the work of the consultation was redistributed to patients and administrators, sometimes causing misunderstandings. The ‘messiness’ of consultations was hard to eliminate. In-house training focused on the technical application rather than associated transformations to practice work that were not anticipated. GPs welcomed varied modes of consulting, but the aspiration of improved efficiency was not realised in practice.ConclusionTele-Doc offers a new kind of consultation that is still being worked out in practice. It may offer convenience for patients with discrete, single problems, and a welcome variation to GPs’ workload. Tele-Doc’s potential for addressing more complex problems and achieving efficiency is less clear, and its adoption may involve unforeseeable consequences.

IMPORTANCE State crisis standards of care (CSC) guidelines in the US allocate scarce health care resources among patients. Anecdotal reports suggest that guidelines may disproportionately allocate resources away from patients with cancer, but no comprehensive evaluation has been performed. OBJECTIVE To examine the implications of US state CSC guidelines for patients with cancer, including allocation methods, cancer-related categorical exclusions and deprioritizations, and provisions for blood products and palliative care.DESIGN, SETTING, AND PARTICIPANTS This cross-sectional population-based analysis examined state-endorsed CSC guidelines published before May 20, 2020, that included health care resource allocation recommendations. MAIN OUTCOMES AND MEASURESGuideline publication before or within 120 days after the first documented US case of coronavirus disease 2019 (COVID-19), inclusion of cancer-related categorical exclusions and/or deprioritizations, provisions for blood products and/or palliative care, and associations between these outcomes and state-based cancer demographics.RESULTS Thirty-one states had health care resource allocation guidelines that met inclusion criteria, of which 17 had been published or updated since the first US case of COVID-19. States whose available hospital bed capacity was predicted to exceed 100% at 6 months (χ 2 = 3.82; P = .05) or that had a National Cancer Institute-designated Comprehensive Cancer Center (CCC; χ 2 = 6.21; P = .01) were more likely to have publicly available guidelines. The most frequent primary methods of prioritization were the Sequential Organ Failure Assessment score (27 states [87%]) and deprioritizing persons with worse long-term prognoses (22 states [71%]). Seventeen states' (55%) allocation methods included cancer-related deprioritizations, and 8 states (26%) included cancer-related categorical exclusions. The presence of an in-state CCC was associated with lower likelihood of cancer-related categorical exclusions (multivariable odds ratio, 0.06 [95% CI, 0.004-0.87]). Guidelines with disability rights statements were associated with specific provisions to allocate blood products (multivariable odds ratio, 7.44 [95% CI,. Both the presence of an in-state CCC and having an oncologist and/or palliative care specialist on the state CSC task force were associated with the inclusion of palliative care provisions.CONCLUSIONS AND RELEVANCE Among states with CSC guidelines, most deprioritized some patients with cancer during resource allocation, and one-fourth categorically excluded them. The presence of an in-state CCC was associated with guideline availability, palliative care provisions, and lower odds of cancer-related exclusions. These data suggest that equitable state-level CSC considerations for patients with cancer benefit from the input of oncology stakeholders.

RECENTLY a practice commonly used by survey research firms to precode questionnaires received widespread exposure in the national media. In an editorial called the "Invisible Ink Caper" (Gemmill, 1975: 22), a highly respected major newspaper stated that it had unknowingly taken part in the unethical practice of coding survey research questionnaires with ultraviolet ink in order to determine specifically who filled out each returned form. Normally respondents are explicitly assured that their responses will be either confidential or anonymous. 1 For instance, the cover letter accompanying the questionnaire may imply that the respondent's returned questionnaire will be completely anonymous. Therefore, precoding the questionnaire constitutes a violation of the "good faith" of the respondents.It is difficult to ascertain just how widespread this practice is. C. M. Crawford reported (1970) that when directors of marketing research were surveyed for a study, 29 percent of them approved of the use of ultraviolet ink in precoding "anonymous" surveys. However, it seems reasonable to conclude this figure is low because, as Crawford cautions in his report, when discussing ethics people tend to say what they think is publicly acceptable yet privately they do what is in their own best interest. A confidential response is made by a respondent whose identity is known but kept secret, whereas an anonymous response is made by an unidentifiable respondent.Editor's Note This article, unlike most POQ articles, is an expression of opinion rather than a report of research findings. Because of the increasing concern about ethical issues in research on the part of the public, government, and researchers themselves, we decided to print it and to invite comments from people who have been involved in one way or another either with public opinion research including mail surveys or with ethical and legal issues concerning research. The comments that follow the article were received at the time we went to press. We invite other comments from readers.John Dickson and William Wynd teach marketing at Eastern Washington State College. Michael Casey and Daniel WyckofTare investigators for the Attorney General's Office of the State of Washington.

A report is presented from a project to delineate clinic efficiency (relationship of effectiveness to cost) and to initiate recommended operational changes in order to improve the provision of health care. A tangential result was a study of the apparent capacity of the clinic and a determination of optimal clinic growth with no deterioration in quality of care and at a reduced average cost per patient.

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