With an average $190,000 owed after graduate programs, early-career radiologists are often faced with six-digit debt straight out of school. And while medical students used to be able to defer loans during residency, that loophole was closed in 2007 with the passing of the College Cost Reduction and Access Act (CCRAA), which left a host of students with high debt-to-income ratios in crisis mode.

Cory M. Pfeifer, MD, outlined in a Journal of the American College of Radiology column the changes that have shaped student loans in the past decade, including the CCRAA closure of the “20/200 pathway” and the implementation of an income-based repayment plan. The law also included the Public Service Loan Forgiveness (PSLF) program—a retrospective loan forgiveness program that requires 10 years of qualifying public service employment.

“Student loans have become a hot topic in recent years,” Pfeifer wrote. “Radiology residents, most of whom now pursue at least one fellowship, are particularly affected by interest capitalization because of the length of training.”

Some of these recent changes are particularly pertinent for today’s early-career radiologists, Pfeiffer said. Below are his key tips for loan success.

1. Familiarize yourself with the PSLF program.

PSLF only applies to federal loans, but those eligible can maximize the amount they’re forgiven by applying for an income-driven data plan as early in their residency as possible. The plan allows forgiveness of remaining student loan balances so long as enrollees make 120 monthly payments under a qualified plan while working full-time for a public service employer.

“It is important to emphasize that PSLF is a retroactive program,” Pfeifer noted. “A borrower does not technically apply for forgiveness until the 120 payments have already taken place.”

However, many recent grads will qualify for the program, Pfeifer said, since most radiologists will begin their careers in PSLF-qualified jobs at government agencies, state universities and nonprofit hospitals.

2. Find out whether your loans are private or federally based.

Students who have participated in federal lending programs have the opportunity to amalgamate federally subsidized loans into federal Direct Consolidation Loans, Pfeifer said. And though Patient Protection and Affordable Care Act provisions have centralized federal student loans, servicing of loans and repayment is often managed by different agencies.

It’s important to note this doesn’t change the federal status of loans, the doctor wrote, but it’s important to know status since it can affect providers’ terms and forgiveness policies. If a student is unsure of the status of their loans, they can consult the National Student Loan Data System.

3. Know your repayment options.

Standard repayment plans will require students to fulfill the terms of their loan within a decade, based on monthly payments that remain static regardless of income. The government also offers a Graduated Repayment Plan and Extended Repayment Plan, but in recent years federal repayment plans have turned more toward income-based strategies.

The first of these plans—known as the Income-Contingent Repayment (ICR) plan—allowed students a 25-year window for repayment. The plan requires individuals to make monthly payments amounting to 20 percent of their discretionary income.

Other options include the newer Income-Based Repayment (IBR) plan, which allows for two decades of repayment at monthly installments of 10 percent of a person’s discretionary income, and Pay as You Earn (PAYE) plans, which follows the same guidelines as IBR. The final plan is a Revised Pay as You Earn (REPAYE) option, which gives a student a 25-year repayment period at 10 percent of their discretionary income.

Different salaries and debt thresholds will mean different options work best for individual radiologists, Pfeifer said, so it’s important for each person to weigh their unique options.

4. Weigh the pros and cons of private refinancing.

For radiologists most interested in non-public service careers and for borrowers with a significant private student loan burden that can’t be consolidated, private refinancing is an option. Private financing companies have offered competitive interest rates and lower payments in recent years, meaning private refinancing is rivaling federal rates in many cases, “but refinancing with a private lender eliminates the possibility of federal forgiveness,” Pfeiffer wrote.

“By shunting borrowers out of the federal system and thus eliminating these borrowers as PSLF candidates, private lenders may be indirectly improving the solvency of the PSLF program,” he said.