Key Takeaways
- Residency and fellowship years still count toward PSLF. The proposal that would have stripped them did not become law.
- Grad PLUS is going away for students starting medical school in fall 2026 or later, replaced by a $50,000 annual and $200,000 lifetime cap.
- SAVE, PAYE and ICR are being phased out by July 2028. RAP launches July 1, 2026 and caps payments at 10 percent of AGI above $100,000.
- A new rule effective July 1, 2026 lets the Department of Education disqualify employers for a substantial illegal purpose, though it estimates fewer than 10 per year.
- Whether RAP beats your current plan depends on your balance, income and how close you are to 120 payments. It is a run-the-numbers decision.
Every physician I talk to has student loans on their mind. And right now, for good reason.
The federal student loan system just went through its biggest overhaul in decades. Earlier this year, there was a proposal that would have stripped residency and fellowship years from counting toward PSLF. That one didn't make it into the final law, which is genuinely good news.
But plenty of other changes did pass. And depending on where you are in your career, they matter. Here's the straight story.
A quick PSLF refresher
Public Service Loan Forgiveness is simple on paper. Work full-time for a qualifying employer, government or 501(c)(3), which includes most teaching hospitals and academic centers, make 120 qualifying payments on an eligible plan, and your remaining federal Direct Loans are forgiven.
The big advantage for physicians has always been that residency and fellowship years count if you're at a qualifying employer. By the time you finish training, you're already a chunk of the way to 120. That piece survived. What changed is everything around it.
Grad PLUS loans are going away for future students
If you're already in medical school or past it, this doesn't affect you. But for anyone starting medical school in fall 2026 or later, Grad PLUS, the program that lets you borrow up to the full cost of attendance, is gone. In its place: $50,000 a year in federal loans, capped at $200,000 lifetime for professional degrees.
Median medical school costs right now run about $286,000 at public schools and $391,000 at private. The math doesn't work. Future students will be filling that gap with private loans, which don't qualify for PSLF, don't offer income-driven repayment, and come with wildly variable interest rates.
What to do: For future physicians, PSLF still exists, but it covers less of your total debt.
SAVE is done. RAP is the new default
If you were on SAVE, you already felt this. The interest subsidy ended August 1, 2025. SAVE, PAYE and ICR are being phased out by July 2028. RAP, the Repayment Assistance Plan, launches July 1, 2026. IBR still exists, but if you take out any new federal loans after July 1, 2026, you lose access to it.
RAP caps payments at 10 percent of AGI for anyone earning $100,000 or more. For a physician making $300,000, that's up to $30,000 a year in loan payments. One upside: unpaid interest gets waived, so your balance doesn't snowball.
Whether RAP is better or worse than your current plan depends entirely on your balance, your income, and how close you are to 120 payments. This is a run-the-numbers decision, not a guess.
One more thing: employer eligibility
Separate from the legislation, the Department of Education finalized a rule in October 2025, effective July 1, 2026, that lets the Secretary of Education disqualify employers from PSLF based on a substantial illegal purpose. The Department estimates fewer than 10 employers per year will be disqualified. If you're at a major academic medical center or public hospital system, the practical risk is low. Several cities are already suing over the rule. Worth watching, not worth panicking over.
What this means for you
If you're in residency or fellowship, your PSLF eligibility is intact. Your bigger question is your repayment plan. If you were on SAVE, pick your next plan before 2028. For most residents, IBR or PAYE will give you a lower monthly payment than RAP at training-level income.
If you're a newer attending on the PSLF track, stay the course. Keep certifying your employer annually. Don't lean too hard on PSLF Buyback; it's still active, but it's not written into law and could get challenged. And run the numbers on staying on IBR or PAYE versus moving to RAP. At attending income, the difference can be significant.
If you're in private practice or not pursuing PSLF, none of this changes your picture much. Your question is still the same one it's always been: refinance, or pay it off on your current terms.
If you're applying to medical school or in your early years, the math is harder than it was even two years ago. PSLF still works well for primary care, pediatrics, long fellowship tracks, and lower-compensated specialties. For higher earners, the case is weaker than it used to be.
What to do right now
You don't need to overhaul anything. But you do need to know where you stand. Know your repayment plan and your transition timeline. Certify your employer using the PSLF Help Tool at StudentAid.gov, and don't wait until you're near 120 payments. Run the PSLF versus refinance math, because what worked three years ago may not work now. And watch the legal developments without letting them rattle you.
The bigger picture
Student loans are the single most emotionally loaded piece of a physician's financial life. You finished medical school with debt north of $250,000, spent years on a resident's salary, and now you're being asked to navigate a system that keeps changing the rules mid-game.
The worst-case scenario, losing residency credit, didn't happen. That's real. But the system has shifted enough that if you haven't looked at your plan in the last 12 months, now is the time.
Frequently Asked Questions
Do residency years still count toward PSLF?
Yes. That was the proposal that didn't pass. Residency and fellowship at qualifying employers still count toward your 120 payments.
Is PSLF still worth it for physicians?
It depends. For physicians with high federal balances working in nonprofit or academic settings, often yes. For future medical students relying heavily on private loans, the benefit shrinks. For private-practice attendings, refinancing is usually the better play. This is a scenario-modeling decision, not a one-size-fits-all answer.
What should I actually do right now?
Confirm your employer is PSLF-eligible. Submit your annual certification. Understand what plan you're on and what it's transitioning to. And if you haven't stress-tested PSLF versus refinance recently, do it.
Tony leads Attend Wealth, a fee-based wealth management firm in Atlanta serving professionals, families, physicians, and business owners. Advisory services are held to a fiduciary standard. More about Attend
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