A Philadelphia native, plastic surgeon Ronald Downs admits he might not have been able to find Indiana on a map a few years ago. Today, he's the president-elect of the state medical association and says he wouldn't want to practice anywhere else.

"Indiana's been very, very good to us," says Downs, who practices in Elkhart.

How good has your state been to you? Have you ever dreamed of moving your practice to some other part of the country? You're not alone. Doctors often fantasize of moving to a far-flung rural locale, where they think the pace is slower, or to a spot near the beach or in a big city.

Of course, such imagining is not reserved for physicians; people in all walks of life wonder if the grass is greener on someone else's lawn. But with incomes higher than the average professional, and physicians in high demand in many places, practicing doctors have a much greater opportunity to actually transfer, and those leaving residency have a wide array of choices. Meanwhile, with malpractice premiums becoming intolerable in many states, doctors also have greater incentive to choose their location carefully.

But if you're mulling a move or weighing options for a first job, don't book your flight before first finding out the best places to go. Physicians Practice researched the business, regulatory, and legal climates for doctors around the country as a way of identifying the friendliest U.S. states in which to hang a shingle. The results may surprise you.

Indiana was one of four Midwest states that made our short list, along with Oklahoma, Michigan, and Wisconsin. South Carolina also made the list. And four states deserve honorable mentions: Alabama, Alaska, California, and Colorado.

The best states in which to practice medicine have a rare combination of low physician density relative to their populations, insurance markets that are competitive but not overly so, and relatively high reimbursement rates despite manageable costs-of-living.

Data examined included Medicare reimbursement levels, which commercial payers often mirror; the malpractice climate as judged by the American Medical Association (AMA); the federal government's cost-of-living index for the states; and the insurance competitiveness of the states, also judged by the AMA. None of the top states is classified as a malpractice premium crisis state by the AMA; such a distinction was an automatic disqualifier.

Finally, the "soft" tests often used to measure a region's quality of life — its weather, the quality of its schools, its crime rate, or its proximity to the beach, ski slopes, and fine restaurants and museums — were not considered. The goal was to find the best places to practice medicine from a business perspective; you'll have to decide for yourself whether these states would also make fun, safe places to live or raise kids.

The top five

Indiana 
The Hoosier State didn't finish at the top of the list in any single category, but it was among the leaders in several and had no striking drawbacks. Though its Medicare reimbursement level was slightly below median, its cost-of-living was even further below median. Only nine states have fewer doctors per thousand people. The competitiveness of its insurance market is low enough that doctors don't feel overwhelmed by the demands of too many payers, yet strong enough that physicians can afford to reject some low-paying or especially burdensome contracts while maintaining robust patient volumes. And Indiana is one of only six states described as "currently OK" by the AMA when it comes to the malpractice climate.

Downs says the Indiana State Medical Society, which represents 5,000 of the state's 8,000 doctors, is another important factor. Its large, active membership helps the organization to be more influential in state politics, making it the envy of states experiencing malpractice crises.

"When physicians are looking to locate somewhere, right now the business climate of a state factors more heavily into their decision than the 'amenities,' so to speak, that perhaps 10 or 15 years ago may have been on the front burner," says Downs. "A few years ago, you could just decide you wanted to be in a warmer climate, or that you grew up in that state and that's where you want to be. But now, with all the stresses on a physician in just running a business from day to day, the business climate has to take priority."

Of Indiana, Downs points to the climate for medical malpractice as being among the friendliest in the nation for physicians. Beyond that, he says, cost-of-living in a city like Indianapolis is lower than similar-sized cities elsewhere, managed-care penetration is reasonably low, and physician-to-population ratios are favorable.
"When you take all those things into account, put them all together, shake 'em up, and see what comes out, Indiana is one of the top five in the country," he says.

His assessment of his adopted home is right on.