title: Evaluating the effect of Japan's 2004 postgraduate training programme on the spatial distribution of physicians.
abstract: BACKGROUND
  In 2004, the Japanese government permitted medical graduates for the first time to choose their training location directly through a national matching system. While the reform has had a major impact on physicians' placement, research on the impact of the new system on physician distribution in Japan has been limited. In this study, we sought to examine the determinants of physicians' practice location choice, as well as factors influencing their geographic distribution before and after the launch of Japan's 2004 postgraduate medical training programme.
  
  
  METHODS
  We analyzed secondary data. The dependent variable was the change in physician supply at the secondary tier of medical care in Japan, a level which is roughly comparable to a Hospital Service Area in the US. Physicians were categorized into two groups according to the institutions where they practiced; specifically, hospitals and clinics. We considered the following predictors of physician supply: ratio of physicians per 1,000 population (physician density), age-adjusted mortality, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004.
  
  
  RESULTS
  Baseline physician density showed a positive association with the change in physician supply after the launch of the 2004 programme (P-value < .001), whereas no such effect was found before 2004. Urban locations were inversely associated with the change in physician supply before 2004 (P-value = .026), whereas a positive association was found after 2004 (P-value < .001). Urban location and area-level socioeconomic status were positively correlated with the change in hospital physician supply after 2004 (P-values < .001 for urban centre, and .025 for area-level socioeconomic status), even though in the period prior to the 2004 training scheme, urban location was inversely associated with the change in physician supply (P-value = .015) and area-level socioeconomic status was not correlated.
  
  
  CONCLUSIONS
  Following the introduction of the 2004 postgraduate training programme, physicians in Japan were more likely to move to areas with already high physician density and urban locations. These changes worsened regional inequality in physician supply, particularly hospital doctors.
authors.affiliation: Department of Social and Behavioural Sciences, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02215, USA. ris245@mail.harvard.edu.
authors.forename: Rie
authors.initials: R
authors.lastname: Sakai
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: D004503:Education, Medical, Graduate; D006801:Humans; D007564:Japan; D008505:Medical Staff, Hospital; D010820:Physicians / Q000600:supply & distribution*; D011156:Population Density; D011365:Professional Practice Location / Q000639:trends; D015397:Program Evaluation; D019035:Rural Health Services; D012923:Social Class; D014505:Urban Population; D000078329:Workforce