Ultimate Guide to Student Loan Debt Management for Doctors
While I think it is entirely possible to finish an undergraduate education debt-free, that is becoming less and less likely for physicians, dentists, attorneys, and other high-income professionals all the time. This lengthy post is going to cover everything you need to know about managing those pesky student loans from student loan forgiveness programs to the best deals on student loan refinancing. Consider this Student Loans 101. I’ve divided the post by level of training, which will hopefully allow you to skip to those parts that apply to you. May this post bring some hope to those struggling under the burden of medical school debt.
Table of Contents
- Student Loans 101
- Student Loan Management During Undergraduate School
- Student Loan Management During Medical School
- Student Loan Management During Residency
- What Happens to Loans in Bad Situations
- Should I Really Pay Off My Loans Quickly?
Student loans are loans issued to students to pay for their education and associated living expenses. As such, it is considered fraudulent to obtain or use them for any other purpose. Unlike a mortgage or auto loan, these loans cannot be foreclosed on. Nobody is coming to do a craniotomy if you don’t pay. However, in exchange for that fact, they have two conditions that make them rather onerous:
- They are offered at rates significantly higher than mortgage rates, especially for graduate/professional school (5-10%)
- They are generally only discharged in the event of death or total disability, NOT bankruptcy
Student loans are divided into two main types—Federal loans (also called Direct Loans) and Private Loans. Federal loans generally have lower rates and also have special income-based payment plans and forgiveness plans so the general rule is to max out what you can borrow in the federal loan programs before taking on any private loans. However, some foreign medical schools qualify for federal loans and some do not. Be sure to consult this list before applying and enrolling in a foreign medical school. Caribbean medical schools are notorious for not qualifying for federal loans, although the ones with the highest match rates (St. Georges, Saba, American University of the Caribbean, Ross) do tend to qualify.
Federal student loans can be consolidated. In this process, numerous loans are all lumped together into one loan and the interest rates are averaged and then rounded up to the nearest 1/8th of a point. This is distinct from the process of refinancing (available only with private lenders) where the interest rate is generally lowered.
Private loans are typically taken out by students who have already borrowed the maximum federal loans for the year ($20,500 per year with an aggregate total of $138,500) although some medical schools are not eligible for federal loans at all. They are never eligible for the federal income-driven repayment programs nor the federal forgiveness programs.
Let’s start at the very beginning. The truth is that you don’t have to borrow for undergraduate school, and I think that very few should. There is a very wide range in the cost of attendance of undergraduate institutions, far wider than the range in the actual quality of the education. By making a few smart decisions and working hard as an undergraduate, most of those who will eventually become doctors can avoid having any undergraduate debt at all. Steps you can and should take in order to finish your bachelor’s debt-free include:
- Choose a school you (+/- your family) can afford to attend without borrowing. If you will be receiving no help at all from your family, this may mean attending a state university in YOUR state or even spending a couple of years “doing generals” at a community college.
- Go where you can get a meaningful amount of scholarship money. It’s rare that those who are academically talented enough to get into medical or dental school aren’t talented enough to get some kind of academic scholarship somewhere, often for full-tuition or even a full-ride. Your part-time job as a high school junior or senior is applying for scholarships.
- Live at home. One of the largest expenses of college is simply your living expenses. These can be cut dramatically by living at home, saving on room, board, and even laundry costs. This might require increased transportation costs, but you’ll usually come out way ahead and get better grades anyway.
- Work hard during the summers. Bust your butt working for tips, working overtime, or even working two jobs when you are out of school. It is not unusual at all for an undergraduate student to return to school in the Fall with $10-15K in their pocket.
If you do end up borrowing for your undergraduate degree, try to only take on subsidized debt. That way the interest won’t be building during medical school and residency. If you will be borrowing for medical school, consider taking out a loan toward the end of your senior year of undergraduate for that purpose. Not only will the interest rate be lower (5.05% vs 6.6% for the 2018-2019 school year) but the first $5,500 will also be subsidized.
The best student loan is the one you never take out. There are a number of techniques for lowering the amount of debt you take on for school.
- Choose the least expensive school you can get into in the least expensive cost of living area. It is difficult to live in Washington D.C., the Bay Area, and Manhattan with a middle-class wage. Trying to do it on borrowed money is a good way to ruin yourself financially.
- Consider taking out the maximum loan amount possible as a senior undergraduate student in order to decrease how much you borrow as a first-year medical student. Not only do undergraduate loans carry lower interest rates than graduate school loans, but they are also subsidized.
- Apply to New York University, Columbia University, and any other schools that may offer free tuition in the future.
- Live frugally. Get roommates. Ride a bike. Minimize meals out, vacations, expensive hobbies, and recreational shopping. Buy books and equipment used.
- Take advantage of any possible family resources. Your parents may be in a position to help with their own savings or current cash flow. If married, your spouse should take a job, preferably with the university which may reduce your tuition.
- Apply for scholarships like The White Coat Investor Scholarship.
- Health Professions Scholarship Program, National Health Service Corps, Indian Health Services, or state primary care programs.
- Don’t take out your loans until you have to. Medical school loans are no longer subsidized and begin accruing interest as soon as you take them out. Some students have even taken advantage of 0% credit card offers to further delay the date when they receive their student loans.
- Consider your student loan burden when choosing a specialty. While finances should not be the primary driver of specialty choice, a $600K student loan burden is not compatible with private practice pediatrics.
As you near medical school graduation, enroll in an income-driven repayment program ASAP. Many doctors have regretted their decision to put their student loans into forbearance or deferment.
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Upon completion of medical school, it is best to divide student loan management into two categories—private loans and federal loans.
As a general rule, doctors are going to pay back their private student loans, so minimizing the interest that accrues is key. The best way to do this is to refinance those student loans as soon as you get out of medical school. Four companies now offer “resident programs” where you can lower your interest rate AND enjoy a lower payment than you would otherwise have to make ($0-$100/month.) While that payment doesn’t cover the interest accruing on the loan, you will end up paying less interest overall because you will have lowered the interest rate from 6-10% to 4-6%. The following WCI Partners offer special resident student loan refinancing programs:
Unfortunately, federal student loan management is much more complicated than private student loan management, particularly for residents. This is due to the presence of Income-Driven Repayment (IDR) programs and forgiveness programs.
Income-driven repayment programs base their payments only on your income and your family size and not on your loan amount or interest rate. These programs are highly beneficial to residents, who literally cannot afford to make “real payments” on their student loans. In some situations, these monthly payments may be as low as $0 but are typically in the range of $100-400 per month. Given that a $200,000, 6% student loan accrues $1,000 per month in interest, these payments typically do not even come close to covering the accruing interest and the loan continues to grow in size during residency.
Income Contingent Repayment or ICR-A is really more of a legacy program. I don’t recall ever running into a doctor enrolled in this program. In ICR-A, payments are 20% of your discretionary income. One advantage it has over the other programs is that you can use it for Parent Plus loans as long as they are consolidated into direct loans.
Income-Based Repayment (IBR) was a new and improved ICR-A. The main feature was a decrease in payments from 20% to 15% of your discretionary income. It is the only IDR you can use with Federal Family Education Loans (FFEL) although those can be consolidated so you can use PAYE or REPAYE. Interest is not capitalized until you leave the program. Payments are capped at the standard 10-year repayment plan level, even if your income rises as it will for many attendings.
Pay As You Earn was a new and improved IBR. It lowered payments from 15% to 10% of discretionary income. To qualify for PAYE, you must have taken out your first federal loan after September 30, 2007, and received a loan disbursement after September 30, 2011. PAYE has some really nice features. First, married folks can file their taxes Married Filing Separately. While this likely increases their tax burden, it may decrease the required payments significantly, which may, in turn, increase the amount of their loans left to be forgiven. Second, like IBR, interest is not capitalized until you leave the program, but even then, the amount capitalized is limited to 10% of the loan balance. Third, just like IBR, payments are capped at the standard 10-year repayment plan level, even if your income rises as an attending.
The newest IDR program, REvised Pay As You Earn (REPAYE), is better than PAYE in some respects and worse than PAYE in others. It maintains that same 10% of discretionary income payment. However, there is no cap on the payments. When you go from being a resident to a high-powered plastic surgeon, your REPAYE payments could be even higher than the standard 10-year repayment plan payments. The forgiveness program associated with the plan (see next section) is also worse. However, REPAYE has one very important feature that none of the other programs have – an interest rate subsidy. This subsidy lowers the effective interest rate for many residents.
Consider someone with $200,000 in loans at 6%. Each month that loan generates $1,000 in interest. If the required payment (10% of discretionary income) is $200/month, then under PAYE $800 would be added to the loan each month. Under REPAYE, only $400 would be added. Basically, half of the interest above and beyond the required payment is waived. This effectively lowers the interest rate for most residents and in some cases, even cuts it in half.
In addition to the more well-known Public Service Loan Forgiveness (PSLF) program, several of the IDR programs have their own forgiveness programs. Remember none of these federal programs have anything to do with private or refinanced loans.
The IBR forgiveness program requires 25 years of payments, but you may make them while working for any employer or not working at all. There are two issues with this forgiveness program. First, most physicians will have paid off their loans completely in less than 25 years because after they finish training, their payments will be equal to those under the standard 10-year repayment program. Perhaps that would not be the case for a very poorly paid physician with a very high student loan burden, but for most, there just won’t be anything left to forgive. Second, the forgiveness is taxable, and after 25 years, the “tax bomb” could grow to as much or more than the original debt, at least on a nominal (non-inflation adjusted) basis.
PAYE improved upon the IBR forgiveness program, offering forgiveness after just 20 years. However, it is still fully taxable at your ordinary income tax rate in the year you receive forgiveness.
The forgiveness program under REPAYE is actually worse than PAYE. Although undergraduate loans are still eligible for forgiveness at 20 years, graduate/professional school loans require 25 years of payments for forgiveness, which is still fully taxable. In addition, because payments are NOT capped at the 10-year standard repayment plan amount, you are even more likely to pay off your loans before 25 years, leaving nothing to be forgiven. The cap is one reason doctors going for PSLF will either use PAYE throughout residency and attendinghood, or switch from REPAYE to PAYE after residency. Remember that switching may require you to make one “full” payment as you move between the programs.
- REPAYE Case Studies
- I Switched to REPAYE and I Like It
- How to Enroll in REPAYE Early and Save Thousands in Interest
Public Service Loan Forgiveness is the granddaddy of the federal forgiveness programs and the only one most doctors should be looking at. Not only does it offer tax-free forgiveness, but it also offers it after just 10 years of payments. If you make a bunch of tiny IBR, PAYE, or REPAYE payments during your training, you may only have to make 3-7 years of “full” payments as an attending before having the rest forgiven. There is a catch, however. You have to be directly employed full-time by a non-profit (501(c)3) while making all of those payments or they don’t count. You also have to make sure you can prove you made all of those payments since the federal student loan servicing companies have a nasty habit of not being able to count payments accurately.
Many residents are tempted to put their student loans into deferment or forbearance during residency and/or fellowship. This is almost always a mistake. Nothing makes me cry more than to run into a doctor who should only be 2-3 years away from receiving PSLF who had their loans in forbearance during a lengthy training period. I hate breaking the news to them that they’ve basically thrown away a benefit worth hundreds of thousands of after-tax dollars. It’s like working for a year or two as a doctor without being paid at all. Deferment is slightly better than forbearance for some people, but they are both very similar for most high-income professionals with loans—you make no payments but the debt continues to grow, sometimes very quickly.
Deferments are granted in six-month increments by your loan servicer and subsidized loans don’t accrue interest. Unsubsidized loans both accrue and capitalize interest. There are several reasons you can get a deferment, but the main one most residents would use is economic hardship, which is limited to just three years. Other reasons include active duty military, unemployment, and going back to school.
With forbearance, interest accrues on both subsidized and unsubsidized loans. Just think of it as a 12-month pause on payments. For most medical students, it is no less attractive than deferment and it is easier to get. There are two types of forbearance. The first is general, where the lender gets to decide whether to give it to you or not. Typical reasons you may get it are financial difficulties, medical expenses, or a job change. Mandatory forbearance, where the lender MUST give it to you if you ask for it, include residency training, if your monthly payment is more than 20% of your monthly gross income (only good for three years), if you are serving with Americorps or activated through the National Guard (and ineligible or military deferment), or if you qualify for special teacher or Department of Defense forbearance programs.
I tell you about these two programs and give you these links because people wonder about them, not because I think people should actually use them. If you are seriously considering deferment or forbearance, you would almost surely be better off with REPAYE. Not only would your payments count toward possible forgiveness down the road, but they may be as low as $0 a month anyway given the REPAYE subsidy. In REPAYE, if your payments don’t cover all the interest, up to half of the interest IS NOT being added on to the loan amount.
Let’s summarize what to do with your student loans if you are a resident. The sooner you know if you are going for PSLF, the easier your decisions become. If you are single, or the sole earner in a married couple, it can also be very easy. But many people would benefit from getting formal advice from a specialist in student loan management. If you are married to another earner and one or both of you is going for PSLF, consider shelling out $300-500 one-time fee as an intern to get advice. It could save you tens, or even hundreds of thousands of dollars. It is relatively easy for them to identify the red flags that indicate you’re doing things wrong and they can help you run the numbers to make the difficult student loan management decisions that involve choosing an IDR program, choosing how to file your taxes, and even choosing whether to use a traditional or Roth IRA or 401(k).
In contrast to residency, where student loan management can be very complicated, involving your taxes and even your retirement account contributions, management as an attending is generally very simple.
Your private loans, which you probably should have refinanced in residency, can be refinanced again and again as long as you can get a lower rate (and you usually can as a new attending). Obviously, refinancing doesn’t actually make them go away, but it helps make more of your monthly payments go toward principal instead of interest. The way you make them go away is by living like a resident and dumping a huge sum on them every month. Even half a million in student loans doesn’t last long against a five-figure monthly payment assault.
Regarding your direct federal loans, you need to finalize your decision of whether to go for PSLF or not. This is usually relatively easy. If you can answer BOTH of the following questions positively, you should go for PSLF:
- Are you directly employed full-time by a non-profit (501(c)3)?
- Did you make a bunch (it varies but in general 20+) of tiny IBR, PAYE, or REPAYE payments while in training?
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- The X Factor
- What Does Live Like A Resident Really Mean?
Best Student Loan Refinancing Deals
Here are the best deals on student loan refinancing I’ve managed to negotiate with the top student loan refinancing lenders:
Fixed 3.47% - 7.59%
Fixed 3.49% - 7.50%
Fixed 3.29% - 6.69%
Fixed 3.49% - 9.99%
Fixed 3.49% to 8.074%
Fixed 3.20% - 6.25%
The secret to refinancing your student loans is to do it early and often. If you ask your fellow White Coat Investors for their regrets, many say they wish they had done it earlier because it was much easier than they thought. While it may appear intimidating at first, most of the companies will give you an accurate estimate of the rate you will eventually receive in 2 minutes online. You’ll need to gather and submit some paperwork, but it’s mostly all the same for all of the companies. So once you gather it and submit it to one, it is very easy to submit it to 2 or 3 more (or even all of them.) Then just take the one that offers the lowest rate.
The rates offered to you will depend on your credit score, your debt to income ratio, and your desired loan terms. Unlike the federal government, which loaned you money just for getting into school, these private companies actually want to make a profit. They only want to loan money to people they think will be able to pay the money back. The best way to get the lowest rate is to accept a 5-year term and a variable rate. If you are willing to live like a resident for 2-5 years after residency and pay off your loans quickly, these terms should be acceptable to you. While there is some legitimate fear of rising rates with a variable rate loan, the truth is that rates have to rise dramatically and/or early in the term in order for you to come out behind with a variable rate loan. If you can afford the worst case scenario, I would at least consider a variable rate loan, and run the math under various interest rate scenarios. Think of a fixed rate loan as a variable rate loan plus an interest rate insurance policy. Since you should only buy insurance against financial catastrophes, someone planning to throw $10K a month at their loans every month for 2 years should not pay extra for a fixed rate. Just having a little more of your payment go to interest instead of principal for a few months is not a catastrophe. Even if rates rise early and dramatically, it will likely only delay paying the loan off by a month or two for someone truly committed to getting rid of them.
Some doctors fear to refinance because they are worried about what will happen to them if their income drops, if they die, or if they become disabled. This is a good reason to avoid putting a co-signer on your loans, but if you read the fine print you will see that most of the private companies have some accommodations for these situations. Often they will give you up to a year without payments in difficult situations (although the interest will continue to build.) Loans are also often forgiven at death and sometimes even for disability. Be sure to read the fine print before signing on the bottom line so you know what to expect if any of these unlikely situations happen to you. Even if the company does NOT offer a death or disability plan, realize that purchasing enough term life insurance or disability insurance to cover the loans or its payments is likely cheaper than paying the extra interest in the government programs!
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- Refinance and Pay Off or Go For PSLF?
- What’s New With Student Loan Refinancing Companies
- Student Loan Refinancing: Real Life Experiences from WCI Readers
A lot of people get confused about loan consolidation, and in fact, use the term consolidating when they mean refinancing. Consolidating generally means taking a bunch of loans and making one loan out of them. While that may increase the convenience of management, it does not actually reduce the interest rate. In fact, it may increase it. With federal loans, the weighted average of your loans is taken and rounded UP to the nearest 1/8th of a percentage point. You can consolidate your loans with the federal government, but to refinance them you must go to a private company and lose the benefits of federal loans such as the income-driven repayment programs and the forgiveness programs.
So why would anyone consolidate their loans if it increases your interest paid? Aside from the benefit of only having one loan to manage, the main reason is that you can turn some loans that were NOT eligible for IDR plans and PSLF into loans that are. The classic examples are Federal Family Education Loans and Perkins loans. By themselves, they are not eligible for those programs, but if consolidated into a direct loan, they become eligible. If you fall in this situation and want to use the IDR or PSLF programs, consolidate here.
Things are a little more complicated for attendings who wish to go for Public Service Loan Forgiveness. These are generally academicians, or at least people who are willing to be academicians for a few years at the beginning of their careers. However, working for the military or the Veterans Administration or other government agencies can also count. There are also a few non-profits out there who directly employ their docs who should qualify for PSLF. Often these jobs pay less than a private practice job, so you need to take into account that sometimes you would be better off with a better paying job and paying off your loans, then going for forgiveness.
The big downside of going for PSLF is that you cannot refinance your loans. Only direct federal loans can be forgiven. So in the event that legislative or regulatory risk rears its ugly head, changing the program, or that you simply change your career goals such that you no longer qualify for it, you will end up paying more interest than you otherwise would have. But for those who stand to get tens of thousands forgiven, I think it is worth running those risks.
In order to maximize how much is forgiven under PSLF, you want to make as many tiny loan payments as possible. That means getting started as soon as possible, and that may be even earlier than you think. The more time you spend in training, the more you stand to have forgiven. If you spend 5 years in a surgery residency, then do a one-year burn fellowship and a one-year trauma fellowship, you may only make three years of “full” attending-size payments, leaving the vast majority of your debt to be forgiven, tax-free.
When going for PSLF, you must continue to make payments in an eligible program. For up to a year after leaving residency, those might still be relatively small payments, further increasing the amount eligible to be forgiven. But eventually, as an attending, you’ll be making “real” four-figure payments toward your loans. At this point, IBR or PAYE is generally the best program to be in because of the cap on the payments at the standard 10-year repayment program amount. That means if you were using REPAYE during residency and/or fellowship, you probably want to switch to PAYE. That will require you to make one regular payment (typical $2-3000) as you move between the programs. This is a typically difficult time to come up with cash due to all the competing needs for your limited cash flow, including:
- Saving up an emergency fund
- Down payment on a home
- Moving expenses
- Buying into a practice
- Maxing out retirement accounts
- Roth conversions
However, it is probably worth it. Of course, if you were in a situation in residency where you weren’t going to qualify for a significant REPAYE subsidy anyway (usually due to a high earning spouse), you should just use PAYE instead of REPAYE all the way through.
Another major complaint of those going for PSLF is that the student loan servicing companies such as FedLoans provide terrible service. They don’t even seem to be able to count payments accurately. This makes it critical that you stay on top of everything. Not only do you need to be an expert at the requirements of the PSLF program (which of your loans qualify, which repayment programs have payments that qualify toward the 120 required monthly payments, and working full-time for a 501(c)3), but you must keep track of all the paperwork, including evidence of every single payment AND a copy of your annual certification forms. Remember, you could end up going to court with the government in order to receive your promised forgiveness. Make sure you have the evidence you need.
In addition, you cannot just assume you will receive forgiveness. Not only could the program change (both the Obama and the Trump administration have proposed changes that would basically eliminate its usefulness to doctors) and you not be grandfathered in, but your employment plans may simply change. Going for PSLF does NOT excuse you from living like a resident for 2-5 years out of residency. However, instead of sending those big 4-5 figure payments to Fedloans, you need to send them to yourself. To your investment accounts, to be specific, creating a “PSLF Side Fund.” This way, even if PSLF doesn’t happen for you, you’re not behind the eight ball.
Hopefully by living like a resident you’ve been able to max out your retirement accounts AND save this side fund up in a taxable account, and you can simply liquidate the taxable account and use the proceeds to pay off the loans. But even if most of that savings ends up in retirement accounts and you can’t (or don’t want) to immediately eliminate the loans at that point, at least your net worth will be where it should be.
Let’s summarize what to do with your student loans as an attending. Private loans should be refinanced whenever possible and paid off quickly by living like a resident. Federal loans should also be refinanced and paid off quickly unless you are directly employed by a 501(c)3 AND made a lot of tiny payments during your training.
If you die or are disabled, what happens with your private loans will be dictated by the terms on their promissory notes. Worst case scenario, if you die they are assessed against your estate. Your parents or siblings etc are never responsible for your loans, but your heirs could be indirectly.
In the event of death, your federal loans are discharged. With Parent Plus loans, the loans are discharged if the student OR the borrower dies.
In the event of permanent disability, federal loans are also forgiven. In a temporary disability, however, you may be limited to use of the IDR programs, deferment, or forbearance.
Student loans generally survive bankruptcy, meaning you cannot wipe them out simply by declaring bankruptcy. However, if you can prove undue hardship, you may be able to have them discharged. Defining undue hardship is going to be up to the judge, but I can assure you that if you qualify for it, you’re going to be in a terrible place financially either way.
Should I Really Pay Off My Student Loans Quickly?
Some people with low-interest rate student loans wonder if they should really pay their loans off rather than invest. While it is intuitively attractive to borrow at a low rate and earn at a higher rate, this decision often ignores two factors.
The first is that most people simply don’t invest the difference. Behaviorally, it is more difficult to maintain focus on building wealth once you have decided to make minimum payments and end up spending the money instead of investing.
The second is that an investment that provides a rate of return higher than the guaranteed return available by paying off your loans usually involves significant risk of loss. However, if you would like to carry your loans a little longer in order to invest inside retirement accounts, I think that’s okay. But I would still plan to have them paid off within five years of finishing training. The financial muscles you develop paying off your loans quickly are the same ones you will use to build wealth toward financial independence afterward. I do not recall ever meeting a physician who regretted paying off her student loan quickly. In fact, most express a feeling of massive relief such as this email I received a few days ago from a two doctor couple who paid off over $700,000 in student loans in 16 months:
This student debt problem is so huge and overwhelming. I had many poor nights of sleep during training fretting about, “How do we pay off this 3/4 million dollar debt?” I feel now an immense stress has been lifted. We can now go forward and make some real decisions about how we want to live out the rest of our lives.
You can slay the student loan dragon. Sit down and get started today. Figure out where you stand; list out your loans by amount owed, payment, and interest rate and add up the total. Then start working on a plan to handle them. You can do it, the entire White Coat Investor Community is rooting for you!
What do you think? What other information belongs in the ultimate guide to managing physician student loans? Have you paid off your loans? What other advice do you have about them for your fellow White Coat Investors? Comment below!