The University of Nevada School of Medicine (UNSOM) is the state's only public medical school, with strong contributions and a history of success in the three traditional missions of academic medicine: clinical service, biomedical and behavioral research, and the education of medical students, graduate students, residents and fellows. A particularly important issue currently is the question of what the State of Nevada gets in return for its support of UNSOM, particularly in terms of new physicians.
One key issue is whether UNSOM should educate more medical students. We have begun the process of expanding, from 62 to 100 students/year, and will accept 68 students for next year. Last year, about 1,400 students applied (a majority of whom were out-of-state), 330 were interviewed (mostly in-state), 83 were accepted, and 62 enrolled (58 in-state). UNSOM has one of the highest "yield rates" of any school in the country, meaning the proportion of accepted students who actually enroll.
This high "yield rate" may be due in part to the relatively low cost for such a high quality education. Compared to peer public medical schools in the Western U.S., UNSOM tuition is relatively low, at about $17,000/year for in-state students. The relatively weak funding of higher education, caused by the weak Nevada economy, results in pressure to raise tuition significantly. It will, in fact, increase to about $20,000 next year with further increases to follow. The problem is that if tuition is much higher, medical students accrue a high level of debt, often $200,000 or more (UNSOM students graduate with debt of about $120,000). A high level of debt has been shown to correlate directly with students choosing highly-paid specialties as a career, which leads to too few family and primary care physicians in underserved urban and rural areas.
The issue of what is the "right" level of tuition can only be answered with an understanding of the high total cost of educating a medical student. If you divide total state support (roughly $30 million/year) by the number of entering medical students (60 or so), the cost of a medical education is about $500,000. That high figure, however, is not a meaningful depiction of the cost and value of medical education. Medical education is more expensive than that of law or dentistry, as a comparison, because of our need for sophisticated basic science teaching based in research laboratories, and for a wide range of full-time faculty physicians based in clinics and hospitals for clinical teaching (which occurs throughout the 4 years).
In addition, state funds support much more than just medical student teaching. Some of the support is critical for high-quality supervision and training of residents and fellows (advanced subspecialty residents). Unlike law and dental students, most of whom start practice after graduation, medical students have three to seven more years of training after medical school. Medical residents are paid a living wage, but their debts continue to grow. Most residents and fellows end up practicing where they trained, so a wide range of specialty training programs is critical to improving the physician workforce in Nevada.
This leads to the final issue which is receiving particular attention at the moment-how many students stay in the State of Nevada. About 40% of students stay in the State at graduation to train. Those who leave do so because of a lack of some of the most popular residencies such as anesthesiology, radiology, ophthalmology and dermatology. Of the 60% who leave, 70% expect to return to the State. So, in fact, about 75% of graduates may eventually end up practicing in the State. Even better is that those UNSOM students who stay in Nevada for residency training have about an 80% chance of staying to practice. These numbers suggest that we should pay particular attention to developing a wide range of new residency and subspecialty fellowship training programs, so as to keep as many medical school graduates as wish to stay. This expanded residency training will need additional state support, which will be critical to UNSOM fulfilling perhaps its most fundamental mandate of training physicians who will improve health and health care in Nevada.