So I threw our lives into the proverbial tizzy this week by seriously considering the idea of joining the military to help pay for PA school. It's a pretty sweet deal -- they cover the entire cost of school as well as paying a $2000/month living allowance (which is considerably more than I earn even *now*), in exchange for which I'd serve a mere three years Active Duty after graduation. I'd be paid a salary (of which I'd spend practically nothing, because I'd be living on a base or a ship with most of my costs covered), get thirty days of paid vacation each year, and be eligible for certain lifelong military benefits, like cheaper insurance, mortgages, and travel. Based on feedback I got from various sources, including one of the doctors who works at my practice and got his MD on the military's dime, it seems like the Air Force would have been the way to go (rather than my initial pick of the Navy): less moving around, less likelihood of being deployed, and fewer drunken twenty-somethings behaving like deranged chimpanzees on their time off.

However, all those great things come at a price: being completely, utterly out of control of your own life. When Uncle Sam said jump, I'd have to respond "How high?" No, make that, "How high, sir?"

I made up a pro-con list, and there were definitely quite a few perks. Physical activity and conditioning, lifelong benefits, travel, adventure. Not to mention that by the end of those three years, not only would I be debt-free, but I'd have enough money in the bank for a down payment on a house.

The downsides, however, far outweighed the advantages. The most obvious con is that I'd have virtually no control over where I was sent. I'd get to 'request' a site, sure, but everyone I've spoken to has admitted that the chances of getting your top pick, or even one of your top five picks, are "slim to none" (and I don't imagine that my status as a "single" woman would help me out any in the competition, where countless others will be able to play the "wife and kids" card). Not to mention that those thirty days of paid vacation are the only thirty days of leave a person gets. If I were sent to San Diego (where a lot of people go), I'd be able to see Liz, oh, maybe once every three months.

Related to that, as well as to my "single" comment -- I'd be essentially 'going back into the closet' in terms of my relationship. Yes, Don't Ask Don't Tell (DADT) will probably be repealed before I would ever serve, but I'm not foolish enough to think that people's attitudes are magically going to change with Obama's signature on the new law. Just because I couldn't be kicked out for my sexuality doesn't mean that it wouldn't be used against me in other ways. And no one can predict the future -- what if it doesn't get repealed quickly? I'd have signed up for a voluntary three years of never being able to bring my partner on base, never hold her hand while in uniform, never even mention her name aloud to anyone. It would be as if she didn't exist, as if that part of me didn't exist... which is exactly what I've spent the past three years trying to acknowledge, not deny. She's told me countless times that if I really, truly wanted this, that she'd support me in it, but I know the emotional fallout would be devastating to both of us. She'd be missing me and feeling as if I were voluntarily denying her existence, and I'd be missing her and feeling guilty for making things so emotionally and financially difficult for her.

My next point is probably best summed up in terms of an exchange I had with my mother when I was in high school. We were watching some Danny DeVito movie about the Army, and as I watched the characters climb the challenge tower, I said, "You know, it might be kinda fun to be in the Army."

Without missing a beat, my mother replied dryly, "Jessica, you have to submit to authority. That's not your strong suit!"

Right she was, and that's still true today. I just don't do well with arbitrary instructions, or people 'pulling rank' on me, or ignorant gun-toting conservatives loudly asserting their backward values. I was warned by several people that I'd have to be able to let those types of things roll off my back, and although I'd like to believe I could, if I'm honest, I'm really not sure I could survive in that type of environment.

After an agonizing 48 hours with all these thoughts rattling around in my head, I came to the conclusion that joining up would, in reality, be a purely financial decision... which is generally not a good reason to do anything. Being in the military isn't something I really, truly want from the bottom of my heart (in fact, it isn't something I ever desired in the least before I found myself in this frightening student loan situation), and I think that for a decision this big, there has to be a motivating force beyond that of money. There are, of course, a lot of perks other than the finances -- but they're all things that I can get from other areas of my life. For example, I can certainly travel the world without joining the Air Force; millions of people do it every day. I'm a credit union member, so I'll already get good rates on house and car loans without military help. I'll be working in the medical field, so I'll have medical, dental, and life insurance provided for me. And as for the physical conditioning, well, what have I been doing for the past six years? Joining swim teams and training for marathons, that's what. I don't need to be a military servicewoman to stay in shape.

Therefore, I've decided not to do it. I just can't get the image out of my head of myself in my cap and gown, sitting with my class on graduation day. Everyone else would be smiling, excited to go out and begin their careers -- and I'd be wide-eyed and panic-stricken, thinking mutely to myself, "What have I done?"

I was right to explore the idea, because it really did have a lot of advantages, and when I look back on this time in my life in ten years, I'll need to understand the decision I made and know that I would make the same choice again if it were presented to me a second time. It's much like the Duke versus ECU decision -- you all remember that. I thought and thought and thought about it, and eventually decided that the many advantages of Duke (great reputation, here in the area, option to study abroad, higher starting salary, etc.) made it worth the higher price. Today, I can still tell you all the reasons that I made that choice, and I still believe one hundred percent that I made the right one.

The Air Force idea, I realize now, was attractive because it was a "Get Out of Jail Free" card. I haven't been afraid of a lot of things in my life, but the idea of $100,000+ in loans is absolutely terrifying to me. Joining up would make the money a moot point. But I can't make a decision like this out of fear. Just because my current financial situation is stressful and scary (right now, I can't even afford a haircut until next payday) doesn't mean that I will always be unable to pay off debt. I have to trust that Duke will provide me with the education and training I need to land my dream job, and that I will in turn be able to pay down my loans relatively quickly without too much financial hardship.

My money situation at twenty-eight or -nine will be quite different from how it is now, at twenty-six. I know that, but I don't really believe it yet -- after all, things have been this hard, if not harder, for the entire three years that I have been an independent adult. When I actually start believing that my life can and will change, I think some of the fear will begin to dissipate.

So I still haven't found any financial aid for PA school whatsoever, and after a conversation with my mom today, I started thinking about how strange that is. With the current trend of MDs all wanting to be surgeons and dermatologists and make the big bucks, and PAs and NPs picking up all the primary care slack, you'd think there would be a lot more aid out there. As my mom put it, I'm "ahead of the curve, as usual." So I spent a large chunk of my day writing this letter. This version is tailored to North Carolina politicians, since that's who I'm sending it to, but feel free to tweak it and send it to anyone you want. The goal isn't necessarily to scrounge up money for myself (unless someone's offering, of course! :)), but rather to make those in power aware of the inequality we're dealing with and try to change things for students down the road.

Dear (insert name here),

My name is Jessica ______; I am a 26-year-old graduate student from North Carolina, and I will soon be entering the Physician Assistant (PA) program at Duke University. I am thrilled to have been accepted to such a wonderful program, and very excited to start school and embark on a rewarding medical career. However, the rising costs of education have recently led me to spend hours in front of my computer seeking out financial assistance. To my shock and disappointment, I have found virtually no aid whatsoever for PA students beyond loans. Given the rapidly changing model of medicine in favor of the mid-level practitioner, I feel that this is an unacceptable gap in the system.

Over the past few decades, we have seen how effective mid-level practitioners such as PAs and nurse practitioners (NPs) can be. As physicians increasingly turn away from primary care and toward higher-paying specialties, PAs and NPs are quietly filling in the resulting gaps, providing a nearly equivalent level of education and experience for a fraction of the cost. Physicians have communicated a high level of satisfaction with PAs, and patients often state that they feel that their PAs spend more time with them than their doctors and take their concerns more seriously. Simply put, not every patient needs to be seen by a doctor. A good percentage of daily care can be easily handled by mid-level practitioners, leaving the truly complex cases for the physicians. This fact is beginning to be recognized globally as well, with multiple PA education programs springing up in the Netherlands, Australia, Canada, the UK, and South Africa. In recognition of our success, American PAs are being heavily recruited overseas, both to teach in these new programs as well as simply to practice medicine, demonstrating firsthand the vital role of the PA and paving the way for new graduates to take over.

Though PAs are increasingly well-respected across the medical field by physicians and patients alike, there exists a blatant inequality in the educational system responsible for the training of these practitioners. While there are multiple programs in place for financial assistance for medical students, there is virtually nothing available for PAs. To use my own institution as an example, fifty percent of a Duke medical student’s demonstrated financial need is covered by internal scholarships and grants, which do not need to be repaid; the student only needs outside funding (loans, external scholarships, or help from family) for fifty percent of his or her costs. For the PA program, however, with an estimated total program cost of $116,000, the only internal aid available is that which is dispersed through the program itself, generally a pittance; current students report having received around one thousand dollars. Following this model, a medical student (who spends twice as long in school and graduates with three times the earning power) will incur the same amount of debt as a PA student, who spends a mere two years in school and receives a far lower salary with which to repay his or her debt.

This financial picture appears to hold true across the board, not only at Duke; moreover, this inequality extends beyond the institutions themselves and into the myriad of external scholarships. There are countless funds available for undergraduates, as well as for nurses, teachers, and doctors, but a graduate student pursuing any other path is often at a loss. Graduate students are commonly newly independent of their parents, living hand-to-mouth on their first real-world job while struggling to pay their bills; yet the vast majority of available financial help goes to undergraduates, who generally pay less tuition to begin with and are often still covered under their parents’ policies for cell phones, health insurance, car insurance, and the like.

There does exist the occasional loan forgiveness program for students entering the medical field, in which student loans are forgiven in exchange for a certain number of years of service in a medically underserved area. The competitive National Health Service Corps (NHSC) is a well-known example. However, should I choose to pursue it, the North Carolina version of this program (NC Health, Science, and Mathematics Student Loan Program) would cover barely 10% of my projected educational costs, yet requires the same amount of service as the NHSC, which covers the entire cost of education. In a state like ours, with such a strong medical reputation, this program seems a halfhearted effort at best.

North Carolina is home to several prestigious institutions of higher learning—more than most states can claim—as well as top-notch hospitals and pharmaceutical companies. In terms of medicine, our state is a clear national leader. As such, I feel that we should pave the way for the rest of the country in demonstrating the value we place on our mid-level practitioners, most notably PAs. Many more PA-specific scholarships and grants must be made available, both within our universities and outside them, and our loan forgiveness program needs to be improved—for if it were made more attractive to pre-PA students such as myself, North Carolina would gain much-needed practitioners where they are in the shortest supply.

There is no reason to think that the current trend away from primary care MDs will shift anytime soon. With the high levels of competence and dedication demonstrated by PAs and NPs across the world, as well as the degree of physician and patient satisfaction, it seems clear that PA education, training, and service should be recognized by helping these practitioners incur less debt. After all, we all need medical care from time to time. It seems a fair exchange to help those who might one day help you.

Thank you for your time.