Hawaii ranked No. 48, fourth from the bottom of the list of states in the U.S. for doctors, according to a study released by WalletHub today.

WalletHub, a personal finance website, compared the 50 states and the District of Columbia across 16 key metrics, ranging from average annual wage of physicians to hospitals per capita in its report on 2018’s Best & Worst States for Doctors.

Hawaii ranked at the bottom, or 51st, for average monthly starting salary of physicians and second from the bottom, or 50th, for average annual wage of physicians, both adjusted for cost of living. Hawaii was 20th in hospitals per capita and fifth in least punitive state medical boards.

The five top-ranking states to practice medicine were South Dakota (No. 1), Nebraska (No. 2), Idaho (No. 3), Iowa (No. 4) and Minnesota (No. 5). Hawaii ranked higher than New York (No. 49), Rhode Island (No. 50) and New Jersey (No. 51).

Data for the study was pulled from the Bureau of Labor Statistics, Association of American Medical Colleges and Centers for Medicare & Medicaid Services, among other sources.