What is the best repayment strategy for medical school loans as a physician?

It depends on three things: employer type, loan balance relative to income, and career stage. Most physicians should evaluate PSLF before IDR, and IDR before refinancing — because each step in that sequence is reversible, while refinancing is not. The right answer is a function of your specific numbers and situation.

What federal loan benefits do I lose if I refinance my medical school loans?

Refinancing permanently eliminates: PSLF eligibility, RAP and IBR enrollment, disability discharge, death discharge, and federal forbearance protections. The analysis should quantify what you are giving up — not just what you are gaining.

Do I have to apply for PSLF, or does it happen automatically?

Not automatic. You must be enrolled in a qualifying repayment plan, submit employment certification annually, and file a forgiveness application after 120 qualifying payments. Physicians who meet every requirement but never certify employment do not receive forgiveness.

What is RAP and how does it affect physicians with student loans?

The Repayment Assistance Plan (RAP) is the new income-driven repayment option launched July 1, 2026 under the One Big Beautiful Bill Act. Monthly payments are calculated as a percentage of your adjusted gross income (1% to 10% depending on income level), with a $10 minimum. If the required payment falls below monthly interest, the difference is waived. RAP payments count toward PSLF. RAP forgiveness comes after 30 years and is taxable. Enrollment is required — the Standard 10-year plan is the default.

Is PSLF forgiveness taxable?

No. PSLF forgiveness is tax-free. IDR forgiveness — forgiveness through RAP or IBR that is not through PSLF — is taxable as of January 1, 2026. A physician forgiven $200,000 through PSLF and a physician forgiven $200,000 through IDR at the end of a 30-year RAP term are not in the same financial position.

Income-Driven Repayment for Physicians

The OBBBA created RAP, ended SAVE, and restricted IBR for new borrowers. Here's how each remaining plan works — and how to decide between them as a resident, fellow, or attending physician.

By Devin Talbot, MBA | Artham Advisors | July 2026

~ 7 min read

Student Loans

OBBBA Updated

Physician Finance

The rules governing federal student loan repayment changed fundamentally in 2025 and 2026. The One Big Beautiful Bill Act (OBBBA, P.L. 119-21) created a new plan — the Repayment Assistance Plan — eliminated three legacy income-driven options, and restricted access to IBR for new borrowers. This page explains what changed, how each remaining plan works, and how to think through the decision as a resident, fellow, or attending physician.