Physician Student Loans (2026): PSLF, Refinancing and Repayment — The Complete Library

Decision path

Start here: what to do at your stage

Find the line that describes you and read the guides it names in order. Most physicians will pass through several of these stages, and the decisions made at each one constrain the next.

1. You are a medical student or about to start school. Federal loans first, private loans last. Since July 1, 2026, new professional students can borrow $50,000 a year and $200,000 in total from the federal government, so every scholarship and service-program dollar now replaces a private loan dollar. Read paying for medical school without Grad PLUS, then medical school scholarships, then private loans for medical school. Final-year students in primary care should look at NHSC Students to Service in the forgiveness guide before residency starts, because eligibility ends when residency begins.
2. You just matched or are starting PGY-1. Pick an income-driven plan before your first bill, confirm your residency employer qualifies for PSLF, and certify your employment. If every federal loan you hold was disbursed before July 1, 2026, IBR is open to you; if any was disbursed on or after that date, RAP is your only income-driven option. Do not consolidate or take a new federal loan until you have read IBR vs. RAP for residents. Then work through student loans during residency and the PGY-1 financial checklist.
3. You were on SAVE. SAVE ended by court order on March 10, 2026, and months in its forbearance do not count toward PSLF. Your servicer's transition notice gives you 90 days from its date; if you do nothing you land in a plan that leaves PSLF behind. Read the SAVE 90-day notice for the choice and for PSLF buyback, then what happened to SAVE.
4. You are a resident or fellow deciding between PSLF and refinancing. Do not refinance during training at a nonprofit hospital. Verify your employer by its EIN with does my hospital qualify, then run the numbers in PSLF vs. refinancing and the PSLF calculator. The table in the next section shows the size of the stakes.
5. You are an attending at a qualifying employer. Stay on IBR if you still can, lower your AGI with pre-tax retirement and HSA contributions, price married-filing-separately with a tax professional, and certify every year and at every job change. Before applying to a state or federal repayment program, check whether the award would only shrink forgiveness you were already going to get. Start with the PSLF guide and income-driven repayment.
6. You are an attending in private practice or at a for-profit employer. PSLF is closed to you, so the job is the lowest total interest your cash flow can handle. Read student loan refinancing for physicians, compare lenders in the refinancing review, and model terms in the payoff calculator.
7. You are open to a shortage area, an FQHC, the VA, the IHS or the military. These jobs come with repayment programs that can stack with PSLF. Read every forgiveness program for physicians, then the state program map, the FQHC playbook and the VA guide.

The big decision

PSLF or refinance?

Everything else is downstream of this one. PSLF forgives the remaining Direct Loan balance, tax-free, after 120 qualifying monthly payments made while you work full-time for a 501(c)(3) nonprofit or a government employer. Payments made during residency count, and they are small because resident income is small. Refinancing trades all of that for a lower interest rate on a private loan.

To show what that trade is worth, we modeled one typical path: the AAMC median balance of $215,000 at a 6.5% average federal rate, a three-year internal medicine residency paid at the AAMC's average stipends, and then the Doximity 2026 internal medicine average of $339,274 as an attending at a qualifying employer. The refinance row uses the lowest published 10-year fixed APR among the lenders we track, 5.15% at KeyBank (as of September 27, 2026), which is a best case; most borrowers are quoted more.

Three things stand out. First, refinancing is not close: even at the best published rate, the refinance path costs about $113,000 more than PSLF, and it takes longer. Second, residency payments are cheap credit. 36 payments of about $327 a month bought 30% of the PSLF clock. Third, the plan matters as an attending: on IBR this internist pays about $2,387 a month, just under the $2,441 cap; on RAP the same income costs $2,586 a month, which is why RAP's forgiveness is $61,000 instead of $129,000.

The full decision framework, with four more salary scenarios, married-filing-separately math and the one-way doors on both paths, is in PSLF vs. refinancing: the 2026 math. The stakes: a physician executing PSLF cleanly often captures six figures in tax-free forgiveness, and a physician who refinances at the wrong moment forfeits all of it, permanently. For every forgiveness path beyond PSLF, including NHSC, state programs and IDR forgiveness, read physician student loan forgiveness.

Your employer decides whether PSLF exists for you

PSLF eligibility is set by who employs you, and it's less obvious than it sounds. The VA qualifies automatically. Kaiser physicians in California can qualify through the 2023 rule for states that bar hospitals from employing doctors directly. Private-equity-owned groups generally don't, and neither does a for-profit group that staffs a nonprofit hospital: the employer on your W-2 decides, not the building you work in. Check the EIN in the PSLF employer search before you sign, and see does my hospital qualify for the structures that trip physicians up.

By specialty

What PSLF is worth by specialty and training length

The same model, run for nine specialties. Each row uses that specialty's typical training length, the AAMC stipend for each training year, and the Doximity 2026 average pay for the specialty as an attending at a qualifying employer. Longer training means more of the 120 payments are made on a stipend, which is why the surgical and fellowship-trained rows show the largest forgiveness on IBR even though they earn the most.

The RAP columns carry the warning. With no payment cap, RAP takes 10% of every dollar of AGI above $100,000, so a high-earning attending pays the loan down quickly. For emergency medicine, anesthesiology and neurosurgery in this model, RAP repays the entire balance before payment 120, and PSLF ends up forgiving nothing. On IBR the same physicians stay at the $2,441 cap and keep six figures of forgiveness. That gap is the reason to avoid any new federal loan or consolidation on or after July 1, 2026 if you hold only older loans, and the reason a fellowship-bound resident should think hard before borrowing again.

Three cautions. Attending pay rises over a career while the model holds it flat, which overstates forgiveness on RAP and on IBR below the cap. Months in the grace period after graduation don't count, so most residents start the clock a few months into PGY-1 and finish it with a few more attending-size payments. And your servicer bases each year's payment on your last tax return, so the first year of residency and the first attending year are usually cheaper than shown. Run your own numbers in the PSLF calculator and the IDR comparison calculator.

Repayment plans

The repayment plans that exist in 2026

Two forces rebuilt the menu: the One Big Beautiful Bill Act, signed July 4, 2025, and the federal court order that ended SAVE on March 10, 2026. For most physicians the live choice is now IBR or RAP; PAYE and ICR are winding down, and the new Tiered Standard plan is a fixed-payment option for loans made on or after July 1, 2026 that does not count toward PSLF. The payment columns below are computed for a single borrower at the PGY-1 stipend ($63,166 AGI) and at the internal medicine average ($310,374 AGI), on $215,000 at 6.5%.

In training the plans are nearly tied: $327 a month on IBR against $316 on RAP. RAP's real advantage in residency is its interest treatment. On a full, on-time payment, RAP waives unpaid interest and tops up principal reduction to $50, so the balance cannot grow; on IBR, unpaid interest keeps accruing. That matters if you will not pursue PSLF and plan to refinance later, because you refinance whatever you owe at the end of training.

As an attending, IBR's cap wins. Married physicians have one more lever: filing separately keeps a spouse's income out of the payment on both plans, often saving more on loan payments than it costs in tax. The detail is in IBR vs. RAP for residents, the RAP guide and income-driven repayment, and the tax side in tax planning for physicians.

What changed

The 2026 law changes

The biggest restructuring of federal student lending in a decade is happening now, and it hits students and current borrowers differently. The One Big Beautiful Bill Act eliminated Grad PLUS loans for new borrowers effective July 1, 2026, capping federal borrowing for new professional students at $50,000 a year and $200,000 in total and pushing the gap toward private loans, and replaced the old income-driven landscape with RAP after SAVE's demise.

Who needs to act: current medical students (borrowing strategy changes mid-degree), residents on legacy IDR plans (transition rules and deadlines apply), former SAVE borrowers with a notice in hand, and anyone whose PSLF projection assumed the old payment formulas. Borrowers whose loans all predate July 1, 2026 lose nothing automatically; the danger is a new loan for fellowship or a consolidation that quietly moves the whole portfolio to RAP.

The loan provisions, the tax provisions and the action items by career stage are in the full OBBBA physician guide.

Repayment programs

Free money first: the repayment programs

Before optimizing repayment, check whether someone will simply pay your loans.

States and federal programs pay physicians up to $200,000 for practicing in shortage areas or federal facilities (California's $300,000 CalHealthCares program is on hold), and “shortage area” includes urban zones more often than physicians assume. The best-designed programs have no clawback: leave early, keep every dollar already paid.

The full map lives in its own hub: state physician loan repayment programs covers Iowa's $200,000 program, Florida's FRAME, the VA's tax-free EDRP (which reimburses payments you've already made, so it stacks with PSLF), and the coordination rules.

One rule to carry from that hub into this one: state awards reduce principal, which shrinks eventual PSLF forgiveness. If you're close to payment 120, an award may duplicate forgiveness you already earned. Model before applying.

Refinancing

If you refinance

Refinancing is right for a specific physician: private-practice or PE-employed with no PSLF path, a high rate, strong income, and no plans to return to qualifying employment. For that physician it's worth tens of thousands. For everyone else, it's an irreversible mistake with a lot of marketing behind it. Our student loan refinancing guide covers the break-even math, the lenders, and what you give up.

Confirm first: you've run the PSLF math; your employer genuinely doesn't qualify; you can live without the federal protections (income-driven flexibility, disability discharge, death discharge); and no state program in your plans is restricted to federal loans (Iowa's incentive program pays only toward federal loans, while California's CalHealthCares accepted private loans).

Then compare rates. The table below comes from the same lender data as our refinancing review, recorded from each lender's own pages (last read September 27, 2026). The lowest advertised fixed APR among them is 3.99% fixed at Splash Financial, but floors like that usually apply to short terms and the strongest applicants, so compare quotes on the same term.

Lender-by-lender detail, eligibility and the resident-deferral programs that allow refinancing during training without full payments are in best student loan refinancing for physicians. Most physicians should choose a fixed rate in 2026; every lender in the table lists a higher variable floor than fixed floor.

Connections

Loans and everything else

Student debt touches every other financial decision. The intersections:

• Buying a house: do student loans affect your physician mortgage? How physician lenders treat IDR payments versus balances, and why refinancing right before a mortgage application can backfire.
• During residency: the resident's financial masterclass and the PGY-1 financial checklist, with the plan-selection and certification steps in year one that determine whether training years count.
• Taxes: residents can usually deduct up to $2,500 of student loan interest; for 2026 the deduction phases out between $85,000 and $100,000 of modified AGI for single filers and $175,000 and $205,000 for joint filers. Check yours with the student loan interest deduction calculator. Pre-tax 401(k), 403(b), 457(b) and HSA contributions lower both your tax and your income-driven payment.
• If the worst happens: federal loans are discharged at death or total and permanent disability, and the discharge is now permanently free of federal income tax. Private loans and cosigned loans are another matter; see what happens to student loans when you die.
• Run your numbers: the student loan payoff calculator puts repayment and refinancing scenarios side by side.
• At the attending transition: the attending playbook shows where the loan decision slots into the first-year sequence alongside disability insurance and the savings-rate baseline, and contract negotiation covers asking your new employer for loan repayment.

The library

Every guide in this library

All 30 student loan guides and reviews on MedMoneyGuide, grouped by the question they answer, plus the 4 loan calculators.

Calculators

• PSLF calculator: Projects your RAP payment and the balance left to forgive at payment 120.
• IDR plan comparison calculator: Your monthly payment on IBR, RAP, PAYE, ICR and the Standard plan, side by side.
• Student loan payoff calculator: Payoff dates and total interest for repayment and refinancing scenarios.
• Student loan interest deduction calculator: Whether your income still allows the $2,500 interest deduction.

Methodology

How we ran the numbers

The PSLF-versus-refinance table, the specialty table, the plan payments and the lender rates are computed when the page is built, from the same data and formulas the rest of the site uses, so they update when that data does; none of those figures is typed in by hand. The law-change and program tables summarize the linked guides and the official sources listed below.

• Balance and rate: $215,000, the AAMC median education debt for indebted members of the class of 2025, at 6.5%, the default rate in our IDR comparison calculator. All loans are federal Direct Loans disbursed before July 1, 2026, so both IBR and RAP are available.
• Income: training years use the AAMC's 2025 average stipend for each PGY year ($68,166 for PGY-1 up to $89,187 for PGY-7) minus $5,000 of pre-tax deductions. Attending years use the specialty's Doximity 2026 average minus $28,900 (the 2026 401(k) limit of $24,500 and the self-only HSA limit of $4,400), held flat.
• IBR: 10% of AGI above 150% of the 2026 HHS poverty guideline for one person ($23,940), capped at the 10-year Standard payment on the starting balance ($2,441). Payments cover interest first; unpaid interest accrues without capitalizing.
• RAP: the sliding scale from StudentAid.gov's OBBBA definitions (1% of AGI per $10,000 bracket, 10% above $100,000, $10 minimum), the same function our PSLF calculator uses. Unpaid interest is waived and principal falls by at least $50 a month, per the plan's rules.
• PSLF: 120 qualifying payments starting with residency, all at a qualifying employer; whatever is left (principal plus unpaid interest) is forgiven tax-free. In practice the six-month grace period after graduation delays the first qualifying payment, which moves a few of the 120 payments into attending years and makes PSLF somewhat more expensive than shown; the one-year lag in the income your servicer uses works the other way.
• Refinancing: IBR during training, then the balance plus unpaid interest repaid over 10 years at the lowest published 10-year fixed APR in our lender data (5.15%, KeyBank, as of September 27, 2026). Your quote will likely be higher.
• Not modeled: raises, dependents, a spouse's income, state repayment awards, taxes on investment of the money saved, and the time value of money. Dollars paid later are worth less than dollars paid now, which favors PSLF further because its payments are spread over the lowest-income years.

Changes

Update log

• October 21, 2026: Rebuilt the hub. Added the decision path by career stage, a computed PSLF-versus-refinance model for a typical internal medicine path and for nine specialties, a repayment plan comparison with computed payments, a table of the 2026 law changes with effective dates, a comparison of forgiveness and repayment programs, a refinance rate table drawn from our lender data, a directory of every loan guide and calculator, this methodology, and three new FAQs. Noted NHSC's FY2026 language-access enhancement.
• September 27, 2026: Rechecked and cited sources inline: the AAMC class of 2025 debt figure, the OBBBA loan limits, and the Iowa and CalHealthCares program terms.

Sources

1. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card for the Class of 2025 (PDF), Association of American Medical Colleges, accessed September 27, 2026.
2. One Big Beautiful Bill Act Updates and definitions, Federal Student Aid, U.S. Department of Education, accessed October 21, 2026.
3. Public Service Loan Forgiveness and the PSLF employer search, Federal Student Aid, accessed October 21, 2026.
4. IDR Plan Court Actions, Federal Student Aid, and the U.S. Department of Education's SAVE next-steps announcement (March 27, 2026).
5. Reimagining and Improving Student Education: final regulations, 91 FR 23768, Federal Register, May 1, 2026.
6. OB3: What Health Professions Students Need to Know (PDF), National Association of Student Financial Aid Administrators.
7. HHS Poverty Guidelines, Office of the Assistant Secretary for Planning and Evaluation (2026 guideline: $15,960 for one person).
8. AAMC Survey of Resident/Fellow Stipends and Benefits, 2025 report.
9. Physician Compensation Report 2026, Doximity.
10. Publication 4681: Canceled Debts, Foreclosures, Repossessions, and Abandonments, Internal Revenue Service.
11. IRS releases tax inflation adjustments for tax year 2026, Internal Revenue Service (student loan interest phase-out).
12. NHSC Loan Repayment Program, Health Resources and Services Administration, accessed October 21, 2026.
13. IHS Loan Repayment Program, Indian Health Service.
14. Education Debt Reduction Program fact sheet (PDF), U.S. Department of Veterans Affairs.
15. Health Care Professional Incentive Program, Iowa Department of Education, accessed September 27, 2026.
16. FRAME Program, Florida Department of Health.
17. Physician Education Loan Repayment Program, Texas Higher Education Coordinating Board.
18. CalHealthCares Grant Guidelines, Cohorts 1-5 (Rev. May 5, 2026), Physicians for a Healthy California, accessed September 27, 2026.
19. Refinance lender rates: each lender's own website, read September 27, 2026; links for every lender are in our refinancing review.