Student Loan Repayment Strategy

Who this is for

Any physician carrying student loans, at any training stage. Attendings get the heaviest branch (PSLF vs refinance vs RAP). Residents and fellows get the IBR holding pattern until the attending contract is signed. Med students get borrowing-stage guidance and a reminder to come back at residency match and again when the offer letter arrives.

The decision this chart helps you make

Physicians face four federal student loan paths after July 2026: IBR (preserved only for borrowers who never take a post-2026 federal loan), RAP (the new Repayment Assistance Plan with no payment cap), refinance to private, or Standard repayment. PSLF still exists for W-2 employees at qualifying organizations. The Public Service Loan Forgiveness math is what makes the W-2 vs 1099 question so consequential. The decision tree is sharper for physicians than for any other profession. Two reasons. First, the debt is large enough that the math has real teeth: a specialist on RAP at $500K AGI pays $4,167 a month versus $3,610 on IBR. Over a 10-year PSLF clock, that is $66,840 in real dollars. Second, the W-2 vs 1099 question is a hard cliff, not a gradient. Emergency medicine, anesthesia, radiology, and hospitalist groups are commonly staffed by 1099 contractors. PSLF requires direct W-2 employment by the qualifying organization. The hospital's 501(c)(3) status does not flow through to a contractor. This chart maps every branch: training stage check, PSLF eligibility (W-2 status), refinance economics (rate gap vs expected market return), the Parent PLUS deadline (Direct Consolidation must disburse by June 30, 2026), and the playbook boxes that turn each path into action steps.

Essentials vs Ultimate

Essentials covers the 80% case: training stage check, federal vs refinanced split, PSLF eligibility, and the standard refinance-vs-IBR decision for attendings. Ultimate adds the post-OBBBA mechanics that most calculators have not absorbed yet: the SAVE transition window, the IBR-vs-RAP math at different income levels, the Parent PLUS consolidation deadline, the 1099 trap for emergency medicine and anesthesia, and the new federal borrowing caps for med students entering after July 2026. Use Essentials for a clean first decision. Use Ultimate if you have Parent PLUS loans, sit in a 1099 specialty, or were in SAVE forbearance.

How to read this chart

Start at the top. The first question (Where are you in training?) will route you to the correct part of the tree. From there, follow the questions down. The chart uses five box types: • Dark green diamond boxes are decision questions (the branching points) • Pale red boxes with ⚠ are warnings and hard deadlines (SAVE transition, Parent PLUS cutoff, 1099 PSLF trap) • Pale orange boxes flag reassessment triggers (things that should make you revisit the chart later) • Pale cream boxes with green headers are action playbooks (numbered steps to execute) • Pale parchment boxes are background context (for med students, or one-time setup info) Most attendings reach a decision within five questions. Use the toggle above to switch to Essentials if the Ultimate view is too dense.