An excerpt from Essays and Echoes: Reflections from a Life in Medicine.
Every year, someone ranks the best states in which to practice medicine, presumably because physicians have been unable to make major life decisions without consulting a color-coded map.
The 2026 WalletHub survey evaluates all 50 states and Washington, D.C., across 19 measures, including physician wages, malpractice costs, hospital availability, projected competition, and burnout. Montana ranked first, New York 51st, and Hawaii 48th.
This poses a problem for me. I hold a Hawaii medical license. I have a residence in Honolulu. I spend the winter there, walking along Kahala Avenue, admiring the Pacific, and occasionally entertaining the fantasy of making my extended winter escape a permanent destination.
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I do not currently practice medicine in Hawaii. Apparently, according to science, I should be looking at Montana instead. Nothing against Montana. I am sure it is magnificent. But when I imagine paradise, my mind has never spontaneously conjured the phrase, “You know what this needs? More February.”
Perhaps I am nuts for keeping my Hawaii license renewed, yet I am apparently in excellent company. Hawaii’s 2025 physician workforce report counted 12,688 licensed physicians, but only 3,647 were providing patient care in the state. In other words, roughly seven in ten Hawaii-licensed physicians are not actively treating patients in Hawaii.
I find this immensely reassuring. There are thousands of us out there, apparently using medical licenses as emotional support documents.
The WalletHub ranking is not frivolous. Its measures are real and consequential. Compensation matters. Malpractice premiums matter. The cost of living matters enormously, especially when a two-bedroom bungalow in Honolulu costs as much as the gross domestic product of a developing nation. Hawaii also ranks near the bottom in physician wages, adjusted for the cost of living.
Still, the LinkedIn discussion accompanying the ranking exposed a fundamental problem with rankings: Doctors stubbornly insist on being human, not numbers. The original poster, physician Joe Pazona, identified what may be the most important missing measure: What percentage of your day could only you do? Now, that is a physician satisfaction survey I would like to see.
- Question 1: During the past week, how many hours did you spend doing something that required four years of medical school and several years of postgraduate training?
- Question 2: How many hours did you spend trying to locate the correct fax number?
- Question 3: At any point, did you find yourself doing clerical work while someone from administration reminded you to “practice at the top of your license”?
- Question 4: Did the phrase “top of your license” trigger an involuntary eye twitch?
No state ranking captures this. A physician in Montana can presumably enjoy low malpractice costs while spending Sunday evening on inbox messages, prior authorizations, scheduling issues, medication reconciliations, and forms designed by someone whose closest encounter with clinical medicine was watching Grey’s Anatomy. Meanwhile, a physician in Hawaii, ranked 48th, may finish clinic, step outside, and discover that a rainbow has just performed an unauthorized wellness intervention.
Which physician won?
The LinkedIn comments made the ranking even less reliable. One physician who had practiced in several states found Tennessee considerably more physician-friendly than the ranking indicated. Another, practicing in Northern Virginia, said that geography mattered far less than owning her practice, controlling her schedule, and having a team to handle administrative work. A Florida physician similarly credited his organization, not the state, with creating a physician-friendly environment.
An anesthesiologist offered another useful formula: Physicians often obtain two of three (place, schedule, and compensation). The fortunate few secure all three. This sounds less like workforce science and more like an episode of Let’s Make a Deal.
- Behind Door Number One: Excellent compensation and on-call every third night
- Behind Door Number Two: Complete schedule flexibility and compensation sufficient to buy an artisanal sandwich
- Behind Door Number Three: Honolulu
Unfortunately, Door Number Three includes a mortgage application.
Several commenters argued that the real variable is the operating environment. One gastroenterologist described working on scheduling at night despite belonging to a “mega group,” then arriving the next morning only to cancel a case because the patient had received incorrect instructions. He observed that higher compensation would not improve that experience.
Exactly. There must be a salary level at which unnecessary administrative work becomes enjoyable, but medicine has apparently not reached that level.
Another commenter offered an equally important criticism: Where are the patients in all this? Patient demographics, resources, health literacy, and community needs significantly shape the practice of medicine. That omission highlights the oddity of asking which state is “best for doctors,” as if physicians were migratory accountants seeking optimal tax treatment.
The work has an object: patients. A state where practicing medicine is easy because patients have excellent access to social support, transportation, education, and specialist resources offers one kind of professional life. A community where a physician is desperately needed offers another. One LinkedIn commenter even suggested that rankings may perversely undervalue places where physicians can contribute the most. Perhaps the best place to practice medicine is not necessarily the one that demands the least of us.
And then there is autonomy, medicine’s most overused endangered species. Dr. Pazona recalled relocating after responding to a job advertisement that used the word “autonomy” four times. He reported there was no autonomy. Four mentions should have been a warning. Treat any job posting that repeatedly promises autonomy the way clinicians treat repeated assurances that a new electronic health record will “save time”: Step away quickly.
So where does this leave my Hawaii license?
Financially, the decision is difficult to defend. Professionally, it may be even harder. Hawaii faces a substantial physician shortage, even as thousands of licensed physicians there do not provide patient care. I am therefore both part of Hawaii’s potential physician workforce and part of its impressive collection of physicians who have apparently said, “Maybe someday.”
But perhaps that is what the license represents: possibility. One day I might decide that my ideal medical geography has less to do with malpractice premiums, CME requirements, or projected competition and more to do with meaningful work, colleagues I respect, patients I can help, and the ability to step outside in January without first searching for thermal underwear.
WalletHub ranks Hawaii 48th. My internal ranking system uses different metrics.
- Ocean: 1
- Weather: 1
- Aloha hospitality: 1
- Winter coat requirement: 51
- Likelihood that I will continue paying to maintain a medical license I may never use: Apparently 1
So yes, keeping my Hawaii license may be irrational. But after writing eight books of medical satire (nine if you include the “best of” volume), I have learned something about irrational systems: Sometimes the only reasonable response is to keep your options open and your license active.
Arthur Lazarus is a physician-author whose work spans narrative medicine, physician leadership, artificial intelligence, health care ethics, medical culture, and fiction. He has published more than 500 articles and essays across scientific journals, professional publications, and online platforms.
He is the author of numerous books on narrative medicine, AI in medicine, career development, and the changing moral landscape of health care, as well as fictional series including Rounds Never End, Sick and Systemic, and Real Medicine, Unreal Stories. His writing explores the forces reshaping modern medicine while preserving a central commitment to story, meaning, judgment, and the human relationship at the heart of care.
He shares updates on LinkedIn.
