The United States Institute of Medicine defined primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community" in 1996 report (1). In Korea, primary care is defined as "the delivery of health care services first encountered by people". It refers to "a discipline in which physicians being well-aware of patients in the context of their family and community, resolve common health care needs of people by maintaining a patient-doctor relationship over time and coordinating health care resources appropriately" (2). Primary care is important in the sense that it is the first and most frequently sought official health care by people in order to deal with their health issues. By establishing the foundation of the health care delivery system, primary care is an efficient health care channel meeting 75%-85% of all medical needs. It also affects the public views regarding doctors and medical service as well as the performance of the overall health care systems (3, 4). In particular, effective primary care can minimize unnecessary expenditure of resources and thus lead to positive health outcomes at lower cost. As patients can access quality health care service through the primary care system regardless of their income level, primary care contributes to the overall health care system by ensuring efficiency, effectiveness, and fairness in care (5, 6).

Despite the aforementioned advantages of primary care, Korea has a weak primary care system which has continued to deteriorate over the years, mainly due to the following reasons: 1) undifferentiated health care delivery system which creates competitive rather than cooperative or complementing relationships between hospitals and clinics; and 2) virtual freedom of choice regarding the medical institution through the availability of multiple channels for patients to directly access hospitals without having to obtain referrals from clinics (7, 8, 9, 10). Moreover, as health care providers in Korea are reimbursed according to the fee-for-service system (8), there is a structural barrier to ensuring key attributes of primary care, i.e. comprehensiveness, coordination, and continuity, and it is, therefore, difficult to maintain ideal patient-doctor relationships (11). Nevertheless, in order to deal with the current health care issues in Korea, including an aging society, increase of chronic diseases, growing demands for health care and the rising cost associated with the advancement of medical technologies, dissatisfaction regarding health care among the general public, including patients, and the difficulties encountered by physicians in operating clinics, it is imperative to take an entirely new approach that veers away from that of previous actions. In fact, other countries have undertaken various initiatives to strengthen their primary care in order to deal with the same issues faced in Korea (3, 11). To this end, the OECD has indicated the problems related to Korea's primary care system, including not being able to effectively deal with the challenges of an aging population and chronic diseases, and has stressed the need for a completely new strategy to improve Korea's primary care system by shifting the focus away from acute care services (12, 13).

From a global perspective, the Korean primary care system falls at the bottom among comparable OECD countries, and the public trust of its quality is also low (3, 14, 15). Therefore, to actively respond to these issues, an effective action plan must be established to improve the existing primary care system of Korea. Previous studies have examined various aspects of primary care including its concept and relevant perception and have reviewed the best practices abroad to benchmark (2, 3, 17). However, most of these studies have simply introduced the best practices from countries abroad to Korea or have made some suggestions for areas of improvement in the Korean health care system, and very few have addressed the feasibility or specific strategies for benchmarking cases from other countries. Furthermore, little or no attempt has been made to receive the opinions of those directly engaged in primary care and to then provide solutions.

Given these issues, our study was intended to understanding the current state, issues, perceptions, and solutions regarding primary care in Korea. The survey was conducted with private practice internists who are specialists and who have been leading Korea's primary care system by representing the largest number of all clinics in Korea.

This study was conducted using clinical internists of Korea in order to understand the current status and issues of primary care in this country. It is essential to survey the opinions of private-practice internists as they are the most representative group of specialists as they comprise the largest share of clinical doctors in Korea and are considered to be the usual primary care providers. Moreover, primary care policies are subject to great struggle regarding their implementation in Korea if they are strongly opposed by internal-medicine practitioners. However, no attempt has been made at the national level by this group to collect their perceptions or opinions regarding primary care, and, therefore, our study is unique and the results of great significance to this field of study.

Our findings show that clinics are perceived to have a very important role in primary care among clinical internists. However, their evaluation of the overall status of Korea's primary care was low and with coordination and comprehensiveness considered to be the two weakest attributes of primary care. Such views closely reflect other study results that evaluated the overall quality of primary care in Korea (3, 14, 15, 16). Coordination and comprehensiveness of primary care have been particularly criticized to be very weak in Korea (21), and our study found that internal-medicine practitioners also shared similar views. Such results may positively contribute to improving the primary-care system in Korea. In other words, given the facts that clinical internists, in principle, agree with the importance of primary care and that they are exactly aware of which areas of primary care need improvement, eliminating the factors that cause their opposition to the primary-care policies may help to alleviate their negative perception regarding these policies.

Our respondents strongly supported the policies intended to help local clinics become effective primary-care providers, such as revising the fee-for-service system, enhancing patients' perception, establishing a strong foundation for the healthcare delivery system, and reducing outpatient services in hospitals, although they showed relatively little support regarding improving the quality of doctors or developing (and making use of) standard, clinical-practice guidelines. In particular, private-practice internists generally believed the distortions of the existing, fee-for-service system to be the greatest deterrent to effective primary care. Under the current low-fee structure, clinical doctors are forced to extend their office hours in order to increase their income and consequently reduce the time they spend treating each patient. Therefore, practitioners are pressed for the time required to provide comprehensive and continuous service and adequate consultation which are critical components of primary care, and both doctors and patients may experience dissatisfaction (16). In addition, given the fact that the fee for identical treatment is the same across the type of medical institution, while the fixed rate applied to hospital-size medical institutions is greater than that of clinics, hospitals may be attracted to expanding their primary-care-based, outpatient service. Therefore, some could argue that the current fee schedule needs to be amended so that outpatient treatment fees for clinics and inpatient treatment fees for hospitals are set higher.

In order to enhance the patient perception, the most crucial step is to redeem their trust in primary care. This problem is directly linked to the first contact among the five attributes of primary care in which patients tend to prefer secondary or tertiary healthcare institutions over clinics. If we blame the phenomenon in Korea where patients prefer to visit hospitals rather than clinics, despite the higher cost, longer waiting and additional travel time, to inappropriate use of medical service, the real problem is overlooked. In fact, from the patient's point of view, visiting a university hospital may be a more economical and efficient choice as it solves all of the healthcare issues at one stop. In other words, the preference for hospitals among patients is derived from widespread distrust in clinical service. Our results showed that internal-medicine practitioners believe that there is no quality difference between hospital doctors and clinicians, not accounting for the facility and its equipment, yet patients had rather strong doubt regarding the quality of care provided in clinics (16).

Therefore, it is imperative to find ways to guarantee the quality of primary care. These measures should include offering various training activities to enhance the quality of doctors as well as developing and making use of standard, clinical-practice guidelines, although this method may be subject to the opposition of clinicians as in the past such initiatives have often been coupled with the government's regulatory strengthening or healthcare fee reduction moves (21). Nevertheless, if the quality of primary care can be raised through the aforementioned measures or if patients and the general public can be well-informed that there is no quality difference between clinics and hospitals in terms of primary-care service and that only discrepancy is the fee for treatment.

In terms of accessibility, the compelling majority of private-practice internists agreed on the need for office hours on Saturday mornings, although regarding other non-business hours, less than 50% agreed. However, as both physical and economic accessibilities to primary care have greatly improved over time in Korea, there is a strong desire among Koreans to see better accessibility in terms of time such as extended office hours on nights, weekends, and holidays (16). Such a demand for improved accessibility in terms of office hours is supported by the fact that non-emergency visits to emergency rooms comprise almost 40% of these visits (22). Yet, respondents indicated that the main reason for their being unable to offer primary care during non-business hours is due to their need to set aside personal time rather than for manpower or economic issues. This implies that clinical internists want to be assured regarding the quality of their personal lives. Therefore, simply increasing the fee schedule for primary care during off-business hours may not improve hourly accessibility, however, a more appropriate and practical policy would be to provide support in favor of joint practices where office hours can be flexibly shared between partners.

This survey confirmed a number of problems related to the three attributes of primary care, i.e. coordination, continuity, and comprehensiveness. Coordination is an essential function of primary-care clinicians, although our study found that coordination among private-practice doctors is quite weak. In fact, 33.1% of our respondents had incidents where they did not make referrals for their patients to other providers for fear of losing their patient business. Also, only 21.7% replied that they contact patients regarding follow-up based on referrals. With regard to comprehensiveness, private-practice internists were well-aware of the need for patient education and consultation regarding disease-prevention efforts and life-style modification, although they did not actively carry out these activities. The main barriers to keeping up with patient education were issues related to the reimbursement system, shortage of manpower and infrastructure, and limited time available for providing care. There were responses, although few, that the reasons patient education is difficult are due to a lack of knowledge regarding patient education and that it is not the duty of clinicians to offer patient education. In answer to the questions regarding continuity, clinical internists agreed on the need to remind patients of their appointment date in order to provide continuous care for patients with chronic illness, i.e. high blood pressure, diabetes, etc., although 87.6% of the respondents said that they do not take any action if patients do not show up for appointments and which indicates insufficient continuous patient monitoring.

When asked about the current management system of chronic disease, the majority of internal-medicine practitioners opposed it, mainly due to stronger government intervention in clinics. Introduced in April, 2012, the current management system of chronic disease provides patient education, standard clinical-practice guidelines, and reminder service to patients with chronic illness for whom it is essential to keep monitoring themselves. Doctors are provided with the health history of patients in order to ensure that they can improve the patients' health and prevent complications. The long-term goal of this management system is to reduce the healthcare expenditure (23). The objective of the program, itself, is straightforward and indisputable. However, given the past government policies that had left out providers and where enforced, lopsided, clinical internists tended to view the current management system of chronic diseases to be aimed at lowering their fees for patient care or amending the reimbursement system. Such a perception has created a strong sense of opposition among clinicians to the chronic-illness care system. In the end, private practice internists still distrust of the government.

As an option for resolving the current tension, this study asked clinicians' views regarding the chronic illness care system led by clinics. The concept is grounded in the fact that private-practice internists are the most appropriate care providers to patients with chronic illness as they actually provide primary care. A clinic-led, chronic disease management system would be by and large identical to the existing system in terms of its context, although the main difference would be that the system will be run by doctors instead of the government. In other words, doctors would be in charge of the entire process of the chronic-illness management system, including planning, implementation, and evaluation, and thus encouraging their active involvement as well as giving them a share of responsibility. The fact that the majority of respondents were in favor of the new management system of chronic disease shows a positive change in attitude in contrast to their previous stance. Therefore, the government should adopt a different set of policies to accommodate such change in attitude among doctors and to regain their trust. The government should learn from past experience in which government-led programs resulted in various, unforeseen side effects and misunderstandings, and in turn introduce a new management system for chronic illness which would directly involve doctors in the program design and implementation as well as its evaluation. Therefore, it is notable to recognize the recent shift in policy direction, namely the 'Health Platform' project launched by the Ministry of Health and Welfare in 2014, which puts emphasis on the autonomy of doctors (24).

This study has some limitations. First, there is a possibility of respondent bias due to the low response rate. This bias might cause problem of generalizability from our study. Second, there is a potential for a selection bias to happen, because the study population in this study was only the member of the Korean Physicians' Association. However, the chances of that happening would not be great, regarding the most of the general internists (3,658/3,967=92.2%), who are opening a clinic, belong to Korean Physicians' Association (25). Third, as our study was only conducted interviewing internal-medicine practitioners, we did not take into account the views of other primary-care providers such as family practitioners and general practitioners. Nevertheless, the reason we particularly surveyed private-practice internists for this research is that, whereas in Europe general practitioners or family practitioners take charge of primary care and specialists treat patients with referrals, such a distinction is not apparent in Korea. It will be meaningful to expand survey target population to other primary-care providers such as family practitioners in the research of future.

The significance of this study is that it is the first attempt to collect the views of private-practice internists at the national level who are the actual primary-care providers and comprise the largest proportion of clinicians in Korea. Internal-medicine practitioners strongly agreed on the importance of clinics for primary care, although their evaluation of the level of primary care in Korea was found to be somewhat low. As identified in a previous qualitative study (16), coordination and comprehensiveness, both of which are essential in managing chronic illness, were considered as the weak attributes of primary care in Korea. Given the strong inclination toward a new management system for chronic illness that gives autonomy to doctors, it is recommended that policy changes should be adopted in such a way that clinical internists are drawn to actively participate in primary-care policies.