The cost of success

TAYLOR ETCHISON ADMITS she didn't grow up aspiring to practice medicine.

When she arrived at Bowling Green State University, the Indianapolis native wasn't sure of her passion. She worked for the student-run newspaper, excelled, and decided to make it a career. 

It wasn't until Etchison was pregnant with the first of three daughters that the notion of donning a white coat took root. Etchison received care at an academic health center and from medical students rounding on clerkships. "I thought this was something I could do," she recalled, "and I could love it forever."

In May, the 35-year-old wrapped up her first year at Indiana University School of Medicine, a journey in its eighth year. It began by earning a graduate degree in gerontology. Then came another two years in a master's program at IU School of Medicine to enhance her credentials to gain a seat in the Class of 2028. 

Six years from now, Etchison envisions herself delivering vital care to older adults grappling with neurodegenerative disorders. Achieving that objective will not come cheaply. Like many of her younger peers, Etchison's education will easily cost six figures and require loans to make the financial arithmetic work. 

It's not a cliché to say Etchsion has mortgaged her future. But in her eyes, it's a sound investment. "This is like a small business loan," she explained. "I believe in myself, what I'm capable of, and what I think I can do for my community in Indianapolis after graduation."

STILL, THE AVERAGE debt load for an IU School of Medicine graduate can be jarring. This academic year, it was estimated to settle at $192,920. While hefty, that's more than $14,000 below the average for all medical schools. How?

Thanks to the generosity of donors, the School of Medicine has increased the amount of scholarship aid flowing to students. It reached $10.1 million this year, making the average award worth almost $19,413 — slightly more than half the tuition cost for in-state students. Most of that aid comes in one-year awards allocated to fourth-year students with a successful academic track record and higher debt loads.

Half of this year's graduating class received a $15,000 award. "You have to have a strategy about every dollar you use," said Paul Wallach, MD, IU School of Medicine’s executive associate dean for educational affairs. "These dollars are scarce." 

IU is also being purposeful about helping students trim costs through tuition caps, robust financial advising, and targeted use of scholarship dollars.

"We're going to keep our cost as reasonable as we can," said Wallach.

Between 1990 and 2010, a period in which state appropriations declined, it wasn't uncommon for tuition to rise 10 percent annually. However, in the past 10 years, the school has never increased tuition by more than 1.5 percent, outpacing core inflation only twice. Over the same period, medical schools around the country increased tuition annually by a median of 2.5 percent, according to data analyzed by the American Association of Medical Colleges.

That makes IU an outlier. And Wallach said IU will remain steadfast in its cost control efforts. "Fortunately, we're a big school, and we have lots of sources of income," he said. "We're going to find other ones in order to support the students."

Since Wallach arrived in 2018, the average debt level for Hoosiers, who comprise almost 80 percent of the student body, has dipped by roughly 7 percent. The percentage of students graduating with debt has also fallen to 73 percent, bringing IU in line with the national median, per AAMC data. 

One key factor is that the IU School of Medicine has been rigorously conservative in how it advises students to take on debt. National benchmarks—suggested by the AAMC and the U.S. Department of Education about the cost of, say, childcare for their three-year-old or for a mortgage in a particular market—are used to determine what a student will need. These are the things—along with transportation, insurance, and other costs—that are covered by loans.

While other schools may suggest students take out the full freight of loans they qualify for, IU has buttoned up the process, encouraging students to take out the minimum of what they will need. It’s a policy built on frugality, but one that can save students substantial amounts of interest later.

"Over time, it will reduce our level of indebtedness compared to the rest of the country," Wallach said. "We're going to let other medical schools catch up."

IU'S FINANCIAL AID office is equally rigorous in its approach to dispensing advice. That task routinely falls to LaTonya Hudson, MS, an assistant financial aid officer. She routinely sits down with every rising second-year student to walk them through budgeting and discuss how much debt they would need to take on to cover their individual requirements.

For first-year students, her focus is simply helping them get their arms around how financial aid works. A student fills out a standard form — called FAFSA — to determine what they're eligible to borrow. Yet, students and families might not understand how the amount is calculated.

"This may be their first time taking out any aid at all," Hudson said. "You're just trying to make them comfortable."

Often, students and parents don't realize the rarity of four-year scholarships. They may not know professional students are only eligible for unsubsidized loans, meaning interest accrues as soon as funds hit a bank account. They might not know about Grad PLUS loans, which can pay for non-educational expenses but also require a credit check. The bottom line is that debt is a reality.

As these future physicians read the paperwork, Hudson keeps a glossary of financial terms open in her web browser. Few students have ever used a fine-toothed comb to account for what they spend at a granular level. Hudson instructs them to bring their bills and their lease, which she plugs into a customized spreadsheet. The student leaves with a custom-built budget.

"Budgets don't fail," Hudson added. "People fail budgets."

The school—Hudson and financial aid director Jose Espada—also does broader tracking. Hudson surveys students at nine campuses to calculate average rent. A few years ago, when she kept hearing about the school's inaccurate textbook costs, she contacted the Office of Medical Student Education. Sure enough, the figures didn't match.

Plugging these fluctuations into an Excel file keeps her finger on the pulse of cost-of-attendance — ultimately shaping Hudson's advice on what a student needs to borrow. "We want the most accurate reflection of what our students are paying," she added.

IT WAS A pivotal exercise for Taylor Etchison.

In 2021, she sat through a presentation Hudson routinely gives during orientation week for students in IU School of Medicine's Master of Medical Science program. Even though she was two years away from applying, Etchison knew she wanted to stay in the Indianapolis area for medical school. To get a head start on planning, she fired off an e-mail to Hudson.

Like many non-traditional students, Etchison's balance sheet looked nothing like that of a student coming straight from undergrad.

She owns a home with her husband on Indy's Southside. While he earns a respectable salary in health care IT, Etchison left behind full-time work with an organization that provides care to home-bound elderly to focus on school. Her father, who lives next door, picks up some slack with childcare and transportation, but Etchison is the first college grad in her family. There was no cash infusion coming from in-laws.

"They say it takes a village to raise a child," Etchison said. "It also takes a village to raise a medical student."

IU's curriculum forces adaptations to financial plans. By a student's fourth year, a student's clerkship schedule means working through the summer — and another three months of bills. Some of those rotations are away from their campus, boosting travel costs. And while the pandemic curbed in-person interviews for residency slots, they haven't disappeared.

While their circumstances are distinct, Hudson says one outlook binds students together.

"You're making a short-term financial sacrifice," she noted. "Once you get MD behind your name, you can do whatever you want to do. Buy a house. Get a Mercedes. Take that trip you put off. You've earned the fruits and worked hard. But you're not going to get there by instant gratification. That comes later."

The playbook Etchison drafted with Hudson was aimed at a straightforward desire: keeping her daughters — Lucy, Helene, and Ophelia, who are between ages 5 and 12 — from "feeling the squeeze." Practically speaking, it's a full fridge, no late bills, and steady health insurance.

"At the end of the day, the financial aspects are focused on keeping our family moving forward in a way where we are happy and healthy," Etchison said.

Hudson's passion and empathy are among the chief reasons Etchison enrolled in the school. After finishing her MSMS, Etchison landed on IU's waitlist and decided to claim a spot in Marian University's osteopathic-based school. Yet, Marian's financial aid office could not clearly articulate what Etchison would have to pay, so she e-mailed Hudson for help.

Once Hudson sent the figures back, she assumed it might be the last time she crossed paths with Etchison. Until August. Hudson learned Etchison's name had been plucked from an alternate list — the same week as Marian's orientation. What did Hudson do? Created a checklist to help Etchison withdraw and take the seat she coveted at IU.

"I didn't meet a single financial aid department that was as helpful or as honest as the one here," Etchison said.

HER EXPERIENCE UNDERLINES a core argument Wallach makes when discussing the price tag to attend IU: delivering value.

Wallach's first task upon arriving at IU entailed rolling out a unified curriculum — ensuring future physicians received outstanding instruction around the state. Since 2014, IU opened new facilities in West Lafayette, Evansville and Bloomington. Next year, a $230 million academic and research building will open its doors in Indianapolis. Students there will have easy access to academic advising, career counseling, and financial aid experts like Hudson. Meanwhile, IU invested in mental health services, which provide counseling at no charge.

"Those services aren't add-ons," Wallach said. "When you add a supportive environment where students believe folks are in their camp, learners do better."

Assuming she holds up her end of the bargain, Etchison might receive an infusion that brings down her loan balance. Until then, she'll adhere to a precise budget and keep working with an outreach core at the Indiana Alzheimer's Disease Research Center, helping it recruit patients for clinical trials.

"This first year of medical school has been more than I could have imagined," she said. "It is exactly what I want to do forever, and I'm grateful IU took a chance on a non-traditional student like me."

Ongoing support from loyal donors allows IU School of Medicine to provide aid that recruits the best talent and rewards it for stellar work in the classroom, lab, and clinic. Make a gift today or contact Caitie Deranek Stewart at cderanek@iu.edu.