title: The impact of Japan's 2004 postgraduate training program on intra-prefectural distribution of pediatricians in Japan.
abstract: OBJECTIVE
  Inequity in physician distribution poses a challenge to many health systems. In Japan, a new postgraduate training program for all new medical graduates was introduced in 2004, and researchers have argued that this program has increased inequalities in physician distribution. We examined the trends in the geographic distribution of pediatricians as well as all physicians from 1996 to 2010 to identify the impact of the launch of the new training program.
  
  
  METHODS
  The Gini coefficient was calculated using municipalities as the study unit within each prefecture to assess whether there were significant changes in the intra-prefectural distribution of all physicians and pediatricians before and after the launch of the new training program. The effect of the new program was quantified by estimating the difference in the slope in the time trend of the Gini coefficients before and after 2004 using a linear change-point regression design. We categorized 47 prefectures in Japan into two groups: 1) predominantly urban and 2) others by the definition from OECD to conduct stratified analyses by urban-rural status.
  
  
  RESULTS
  The trends in physician distribution worsened after 2004 for all physicians (p value<.0001) and pediatricians (p value = 0.0057). For all physicians, the trends worsened after 2004 both in predominantly urban prefectures (p value = 0.0012) and others (p value<0.0001), whereas, for pediatricians, the distribution worsened in others (p value = 0.0343), but not in predominantly urban prefectures (p value =0.0584).
  
  
  CONCLUSIONS
  The intra-prefectural distribution of physicians worsened after the launch of the new training program, which may reflect the impact of the new postgraduate program. In pediatrics, changes in the Gini trend differed significantly before and after the launch of the new training program in others, but not in predominantly urban prefectures. Further observation is needed to explore how this difference in trends affects the health status of the child population.
authors.affiliation: Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America ; Department of Medical Education, Juntendo University School of Medicine, Tokyo, Japan ; Department of Pediatrics and Adolescent Medicine, Juntendo University School of Medicine, Tokyo, Japan.
authors.forename: Rie
authors.initials: R
authors.lastname: Sakai
authors.forename: Wei
authors.initials: W
authors.lastname: Wang
authors.forename: Norihiro
authors.initials: N
authors.lastname: Yamaguchi
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Tamura
authors.forename: Rei
authors.initials: R
authors.lastname: Goto
authors.forename: Ichiro
authors.initials: I
authors.lastname: Kawachi
mesh_terms: D002648:Child; D002662:Child Health Services / Q000706:statistics & numerical data / Q000639:trends; D004503:Education, Medical, Graduate / Q000706:statistics & numerical data*; D005843:Geography; D006801:Humans; D016014:Linear Models; D010372:Pediatrics / Q000706:statistics & numerical data* / Q000639:trends; D010820:Physicians / Q000706:statistics & numerical data* / Q000600:supply & distribution / Q000639:trends; D019035:Rural Health Services / Q000706:statistics & numerical data*; D019037:Urban Health Services / Q000706:statistics & numerical data*; D000078329:Workforce