We could make even a better case for undergrad institutions. Some undergrad schools have higher tuition and COA then most state med schools. My HS buddy went to undergrad with COA of ~60k/yr. I agree that pre-clinical years do not cost ~40k just for lectures alone, but there are other resources students use during those 2 years. Plus, that 40k pays for library place and resources, people taking care of the facilities, administration, utilities, wellness center (if you have one), labs, clinical exposure or SIM, SIM patients, exam software and support, IT support, etc. There is a lot more we can list that is paid by our tuition. Unless we get rid of physical med school completely for the first 2 years, I dont see how we can really unjustify tuition for the first 2 years. Even if you study on your own somehow through other resources and do board prep on your own, you would have to pay for all the tests and support that comes with it. And then go straight into clinical years. But again, you need the school and its support for rotation spots.