Physical inactivity is a global health burden. Promoting physical activity in primary care through physical activity counseling is an effective intervention. This article provides an overview of and perspectives on physical activity counseling in primary care. The identification of physical inactivity as a health problem may increase the awareness of physical inactivity among patients and primary care providers, which will lead to an action plan. The contents of physical activity counseling should be based on evidence-based recommendations. Safety issues should be evaluated appropriately to optimize the utilization of primary care services. Physical activity counseling methods should be “tailored” for an individual using appropriate counseling methods and setting-specific resources. Multilevel barriers to physical activity counseling in primary care (i.e., healthcare providers, patients, and systems) must be addressed. Setting-specific strategies to overcome these barriers should be implemented to maximize the effectiveness of physical activity counseling in primary care.

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Background
After the referral system had been established, a tendency of patients who prefer to consult themselves to a specialist with 'self requested referral' is increasing in university hospital family medicine clinics. This study was conducted to know which factors of patients who for the fi rst time visited university hospital family medicine clinic to require medical request for 'self requested referral' to a specialist infl uence 'self requested referral' tendency. Methods: Among 905 patients, 647 agreed to the questionnaire were included in this study. We divided the patients in two, the 'self requested referral' group and the 'general patients' group that does not. Patients completed a four-item, selfadministered questionnaire. Results: 'Self requested referral' group tended to have no experience in family medicine and tended to be negative about the need for family medicine (P < 0.001) The factors that have effect on 'self requested referral' are age, occupation, education, experience of family medicine, and recognition degree of necessity of family medicine. Patients in 20-39 of age, who were white colored, higher education had higher tendency of 'self requested referral' and patients who had no experience in family medicine and lower degree of recognition about the necessity of family medicine had higher tendency of 'self-referral'. Conclusion: It is necessary to fi nd ways to increase satisfaction of patients who have factors that have effect on their 'self requested referral' tendency such as age, occupation, education, experience of family medicine, and degree of recognition about the necessity of family medicine.

Background
After referral system had been established, patients wishing to consult with a specialist with 'self- referral' in mind is increasing in university hospital family medicine clinics. This study was conducted to know whether those by self-referral to a specialist in a university hospital could benefit from family physician's consultation or not. Methods: Three hundred and sixty patients were serially assigned to either 'simple referral' group provided with a referral note without consultation or 'referral after consultation' group with consultation from a family physician. Patient satisfaction was rated by using questionnaires with 5-point Likert scale. Results: Patients in the 'simple referral' group were more satisfied with the whole process of family physicians' consultation compared to the 'referral after practice' group in both the appropriateness and patient satisfaction of the consultation (both, P＜0.001). Males, longer encounter time, and shorter waiting time were significantly influenced patient satisfaction compared to each counterpart. Conclusion: Patients who want only a referral note from a family physician in a university hospital may received some benefit from the coordination and comprehensive care by a family physician. Health delivery system should be rectified according to the consideration of the role of the primary care physician such as a family physician. (J Korean Acad Fam Med 2008;29:325-329)

Background
Consultation and referral are important characteristics of modern medicine which has become more segmented and more specialized. In particular, they give essential value to family practitioners to coordinate patients accordingly for proper care. This study analyzed the referred patients in family practices under Cheonan practice based-research network (CPBRN). Methods: The data was collected via questionnaire in ten family clinics under CPBRN system during the four weeks from June 15, 2006 to July 12, 2006. Results: The total number of referred cases was 103 (0.7%) out of a total of 14,466 office visits. Among the total, 68.9% of referred cases was physician-drived and 31.1% was patient-requested. The reason for referral were 'to get a second opinion of specialist' (34), 'high severity' (20), 'lack of examination tool' (18), 'lack of skill' (10) and 'no response to treatment' (2) in physician-drived cases, whereas in patient-requested cases, they were 'request for advanced hospital' (26) and 'want to meet specialist' (2). The patients were referred to tertiary hospital in 66.7%, secondary hospital in 15.9%, and other specialists of primary setting in 10.1%. Overall, 66.7% of the referred hospital was located in the city area. The main health problems of referred patients was divided into 'gastrointestinal' (17.5%), 'musculoskeletal' (13.6%), 'dermatology' (10.7%) and so on. The speciality consulting physicians were 'internal medicine' (34%), 'pediatrics' (13.6%), and 'orthopedic surgery' (10.7%) specialists. Conclusion: The referral rate of family practice in Korea was 0.7%. The main reason for referral was 'to get a secondary opinion of a specialist'. The most common referral problem was 'gastrointestinal'. 'Internal medicine' was the most frequently consulted specialty. (J Korean Acad Fam Med 2007;28:286-291)

Background
: Since March 1, 1989, a new health care system has been introduced. But the departments of ENT, ophthalmology, dermatology and PMR (rehabilitation medicine) in tertiary health care hospitals were exempted from the new system and were allowed to see patients directly. Thereafter, the Ministry of Health revised the National Health Insurance regulation, and required the above departments to see patients only with referral. This study was done to analyze whether the revision has contributed to providing adequate specialized medical services and to know what role family physicians can assume under revision by analyzing the referred patients.

Methods : From November 1998 to June 2000 and from July 2000 to February 2002, both 20 months, we reviewed the charts of 331 patients who were referred from family medicine department of KHMC (Kyung Hee Medical Center) to the above four departments and analysis has done.

Results : During both periods, the number of cases increased from 94 to 237, and the patients group had no significant difference in age and sex. Reviewing the number of referred cases, before revision, cases were concentrated to the department of ENT and to PMR. After revision, cases were evenly distributed in three departments. except for PMR. Reviewing referral contents, the three departments except for dermatology showed no significant difference.

Conclusion : The sum of cases increased by 2.5 times, but the three departments except for dermatology showed no significant difference in referral and diagnosis content. In dermatology, the majority of the patients wanted a referral with the objective of obtaining a referral paper. Therefore, we can consider that the revision didnot contribute to specialized medical services. But after revision, referral cases to ophthalmology and dermatology increased by 4 and 6 times. We recommend that family physicians know and experience more about these.

Background
: After amendment of the national health insurance law to enforce and reform primary health care, the number of family medicine out-patients was increased. Some patients requested referral. Therefore, this study was made to reveal family medicine residents' perception of attitude towards request for referral.

Methods : The self-administered questionnaires were collected by post mailing (July 1 to July 30, 2002) and by e-mailing (July 25 to August 10, 2002). The questionnaire contained the followings: general characteristics, issues of referral request, influence of referral request in training, and influence in private family clinics.

Results : The overall response rate was 22.2% (93/418). Patients need was the most common cause of referral (62.0%). Among the total, 46.2% of respondents gave answers that increasing number of patients at the family medicine out-patient clinic was beneficial in increasing their experience. Also, 55% of respondents replied that the present state of family medicine out-patient system influenced lowering of motivation in training. Overall, 63.4% of respondents replied that the present state of family medicine out-patient system led a trend of distrust to private family clinics.

Conclusion : Patients request was the most common cause of referral in family medicine out-patient clinic. The present state of referral system in family medicine out- patient clinic influenced lowering of motivation in training and a trend of distrust to private family clinics.

Background
: Appropriate referral without failure, one of important health care services provided by primary care physicians, is very helpful not only to patients but also to the referring physicians. This study was performed to observe the rate of referral failure and to evaluate the factors related to referral failure.

Methods : from June 10 to October 31, 1997, all referrals made in the department of family practice in the Samsung Medical Center were studied. Structured questionnaires inquiring of referral initiator, physician's view of clinical severity and referral necessity, and the reason for referral were completed by referring physician whenever each referral was made. On the 60th day after referrals were initiated, medical records of the referred patients were reviewed to obtain the information on the demographic characteristics of the patients referred, the contents of referral, and the patient's attendance the specialist clinic after referral. Each referral was audited by five family physicians working at the Somsung Medical Center to examine the appropriateness of the time when the referral was initiated. The patients who did not attend at specialist clinic to which they were referred to were telephoned to ask about the reasons for the referral failure. Chi-square test and multiple logistic regression analysis used to evaluate the factors related to referral failure.

Results : During the study period, total of 477 referrals were made among 9.384 encounters and the referral rate was 5.08%. Fifty-eight patients failed to complete the referral process within predetermined period and the rate of referral failure was 12.16%. The risk of referrals failure was significantly low in cases whose referral time was assessed as appropriate(odds ratio=0.53). Female was a significant increasing the risk of referral failure(odds ratio=1.91). Being too busy(24.14%) was the most common reason for referral failure. Other reasons included improvement or resolution of symptoms(12.06%), information on the referral was not give(6.9%) and too great a distance the between hospital and the patients home(6.9%). Four patients forgot to attend the hospital.

Conclusion : Considerable proportion of patients being referred did not complete the referral process. Timely referral and sufficient discussion between physician and patient being referred seems to be necessary. to prevent referral failure.