General internists' perspectives regarding primary care and currently related issues in Korea

Although primary care has been recognized as an essential element of the healthcare system, the primary healthcare of Korea has not been highly valued. Listening to the voices of physicians who are engaged in primary care should be the first step for improving the level of primary care in Korea. In this study, we conducted a questionnaire survey of general internists to investigate their perspectives regarding primary care, and which included the evaluation of current primary care, perception of the five, key attributes of primary care, and their opinions regarding the management system of chronic diseases. A total of 466 general internists' responses were used in this analysis. The results showed that primary care is considered to have an important role, according to general internists, although their evaluation of the overall status of primary care in Korea indicated that it is poor. The respondents also indicated that the functions of coordination and comprehensiveness in primary care, which can be integral for treating patients with chronic diseases, are most vulnerable. Given the high level of agreement regarding the need for a new medical management system for chronic diseases, based on physicians' autonomy and provided by clinics, establishing a policy encouraging the participation of general internists should be emphasized. Graphical Abstract Keywords: Internal Medicine, Primary Care, Health Policy, Chronic Diseases INTRODUCTION 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.