Context: Recruiting and retaining physicians is a challenge in rural areas. Growing up in a rural area and completing medical training in a rural area have been shown to predict decisions to practice in rural areas. Little is known, though, about factors that contribute to physicians' decisions to locate in very sparsely populated areas. Purpose: In this study, we investigated whether variables associated with rural background and training predicted physicians' decisions to practice in very rural areas. We also examined reasons given for plans to leave the study state. Methods: Physicians in the State of Wyoming (N = 693) completed a questionnaire assessing their background, current practice, and future practice plans. Findings: Being raised in a rural area and training in nearby states predicted practicing in very rural areas. High malpractice insurance rates predicted planning to move one's practice out of state rather than within state. Conclusions: Rural backgrounds and training independently predict practice location decisions, but high malpractice rates are the most crucial factor in future plans to leave the state.