This leads doctors to use a few strategies to try to maximize the amount forgiven. First, some types of loans (eg, Federal Family Education Loans and Federal Perkins Loans) don’t qualify for forgiveness unless they are consolidated into a Federal Direct Loan. Second, you can enroll in an IDR program and start making payments late in your fourth year of medical school, essentially increasing the percentage of payments you make while your income, and thus your payments, remain low. Third, contributing to tax-deferred retirement accounts during residency further lowers your income and your required payments. Finally, some physicians married to high earners find it advantageous to file their taxes as “married filing single” while enrolled in an IDR program. Even though this often increases their combined tax burden, it can also reduce the borrower’s income (at least in the IBR and PAYE programs) and thus their spouse’s required payments.

A longer training period can also help maximize forgiveness. A physician who spends seven years in residency and fellowship may need to make full payments for only three years as an attending before receiving forgiveness.

Private student loans are never eligible for PSLF, and the best strategy for managing those usually involves refinancing to a lower rate as soon as possible (usually shortly after medical school graduation) and paying them off early in your career. Several lenders allow very low payments during training, just like the federal IDR programs.

Caution: Refinancing your federal direct loans can be a big mistake if you later end up working for a 501(c)3 after residency graduation. Another common error is putting your loans into forbearance or deferment during training, which prevents the accumulation of lower IDR payments that would later allow for significant forgiveness under PSLF. If you make IDR payments throughout residency and work full-time for a 501(c)3 after residency, going for PSLF instead of refinancing the loans generally works out better mathematically than refinancing, even if the interest rate is higher.

Many students, residents, and attendings worry Congress will change the rules and take PSLF away. That is a significant risk—both the Obama Budget of 2013 and the Trump Budget of 2018 proposed doing away with the program as we know it. The Prosper Act, currently in House committee, would also cause significant changes to the federal loan programs if it becomes law in its current form.

However, in the past, when federal student loan programs were changed, those currently in the program were usually grandfathered into the old program. A good way to hedge this legislative risk is to make large student loan payments as an attending that would allow you to pay off your loans within two to five years after residency completion, but make those payments to your own investing account. Then, if something happens to PSLF, you can simply take those funds and pay off the loans. If you do receive forgiveness, you can use that money to bolster your retirement nest egg or other savings goals.