Roughly 43 million Americans carry federal student loan debt, but the weight of that burden lands very differently depending on who in a household is carrying it. When the debtor is a medical resident earning roughly $60,000 a year while their partner earns nearly double that, the math gets complicated fast — and the federal programs designed to help can feel like they were built for someone else entirely.
That was the situation Aisha Patel described when I met her at a coffee shop in Chicago’s West Loop neighborhood on a Tuesday afternoon in late March. She arrived with a notebook — actual paper, she pointed out — filled with loan figures, projected repayment timelines, and a color-coded spreadsheet she’d printed the night before. She is 29, works as a marketing manager at a SaaS startup, and earns $95,000 a year. Her fiancé, Deven, is a second-year internal medicine resident. He earns $58,000. Together, they look comfortable on paper. In reality, Deven is carrying $280,000 in federal medical school loans.
The Number That Sits at the Center of Every Conversation
Aisha did not hesitate when I asked her what the hardest part of the last two years had been. “It’s not the debt itself,” she told me. “It’s that the debt has an opinion about every single thing we want to do. We want to get married. We want to buy a place. We want to eventually start a family. And every single time, $280,000 shows up to that conversation uninvited.”
That figure — $280,000 — is not unusual for physicians. According to the Federal Student Aid office, the average medical school graduate leaves with over $200,000 in debt, and many exceed that significantly depending on whether they attended a private institution. Deven attended a private medical school in the Midwest. His loans are entirely federal, which, Aisha acknowledged, is actually the better scenario for what comes next.
The debt-to-income ratio problem is real and immediate. Aisha had spoken with a mortgage broker in January about buying a condo in Logan Square. She told me the broker ran their numbers and came back with a frank assessment: Deven’s current loan payments, even on an income-driven plan, were pulling their DTI ratio above the threshold most conventional lenders require. “He was kind about it,” she said. “But the message was basically, not yet.”
What Income-Driven Repayment Actually Means for a Resident
The federal government offers several income-driven repayment plans designed to cap monthly loan payments as a percentage of a borrower’s discretionary income. For medical residents, these plans can dramatically reduce what would otherwise be crushing monthly payments during the lowest-earning years of their career.
Deven is currently enrolled in the SAVE plan — the Saving on a Valuable Education plan — which, under its standard calculation, sets payments at 5% of discretionary income for undergraduate loans and 10% for graduate loans. For Deven’s income and loan type, Aisha told me his monthly payment comes out to approximately $340. Without an income-driven plan, a standard 10-year repayment schedule on $280,000 at current graduate loan interest rates would run closer to $3,000 a month.
The tradeoff, as Aisha explained it with the kind of precision that comes from having researched something obsessively, is that lower payments mean the balance grows. Interest accrues on what isn’t being paid. Under SAVE, the federal government covers unpaid interest in some circumstances, which prevents runaway balance growth — but the underlying principal is not going anywhere fast on $340 a month.
Public Service Loan Forgiveness: The Program That Could Change Everything — If It Works
Here is where Deven’s situation potentially shifts. Because he is completing his residency at a nonprofit academic medical center — the type of institution that qualifies as a public service employer under federal guidelines — he is eligible to pursue Public Service Loan Forgiveness, or PSLF.
Under PSLF, borrowers who make 120 qualifying monthly payments while working full-time for an eligible employer can have their remaining federal loan balance forgiven tax-free. For Deven, who started residency in 2024, that clock began ticking. If he continues working at nonprofit or government-affiliated hospitals — which is the path for the majority of academic physicians — he could reach forgiveness in 2034.
Aisha knows this plan cold. What she is less certain about is whether to trust it. PSLF has a documented history of rejection — at various points in the program’s early years, approval rates were in the single digits, largely because borrowers had been placed on the wrong repayment plan or had paperwork errors. The Federal Student Aid PSLF page has been updated with clearer guidance, and the approval rate has improved significantly since program reforms in 2022 and 2023 — but the anxiety lingers.
“I keep thinking about all the people who did everything right for nine years and then found out they had one wrong form,” Aisha told me. “We’re filing the employer certification every single year. We’re not waiting until the end. But I’d be lying if I said I completely trusted it.”
The Wedding, the Condo, and the Argument They Keep Having
Aisha and Deven have been engaged for eight months. They have not set a wedding date. This is, she told me, a source of ongoing tension — and it connects directly to the loans in ways that aren’t always obvious from the outside.
Marriage has a direct impact on income-driven repayment calculations. Under the SAVE plan, if a couple files taxes jointly, the borrower’s payment is calculated based on combined household income. For Deven, that means the moment he and Aisha file jointly, his monthly payment could jump substantially — because Aisha’s $95,000 salary gets factored into his discretionary income calculation.
Some couples in this situation file taxes as Married Filing Separately specifically to preserve the lower IDR payment. That choice comes with its own costs — losing eligibility for certain tax credits and deductions. It is a calculation with no clean answer, and it is one of the things Aisha and Deven are still working through.
“We had this whole argument where he said maybe we should just elope and figure out the tax stuff later,” she told me, laughing in a way that held some exhaustion in it. “And part of me thought, honestly, that’s not the worst idea. Not for romantic reasons. Just because it’s one less thing to optimize.”
The wedding budget question feeds directly into the debt question. A meaningful ceremony with family — what Aisha describes as what she actually wants — would likely cost between $25,000 and $35,000 in the Chicago market. That is money that could go toward the loan principal, or toward the down payment they’d need to clear the DTI hurdle with a mortgage lender.
What Aisha Wishes She Had Known Earlier
When I asked Aisha what she would go back and tell herself two years ago, before the engagement, before she’d spent dozens of hours inside loan servicer websites and Reddit threads and Department of Education FAQ pages, she was quiet for a moment.
“I wish someone had told us that federal loans are actually the more manageable version of this problem,” she said. “We spent so much time being scared of the number that we didn’t realize the number had options attached to it. Private loans don’t have PSLF. Private loans don’t have SAVE. If Deven had taken private loans for any of this, we’d be in a completely different situation.”
She also talked about the emotional cost of being the higher earner in a couple where debt belongs to someone else. Aisha is not legally obligated for Deven’s loans. They are his, in his name, from before their relationship. But practically speaking, those loans live in their shared life now. They affect what she can buy, where they can live, how they plan for the next decade.
According to Federal Student Aid’s repayment resources, borrowers are encouraged to review their repayment plan annually and recertify income on time — a missed recertification can result in payment increases and interest capitalization. Aisha has put Deven’s recertification date in both of their calendars.
As I packed up to leave, Aisha flipped through a few more pages of her notebook. She pointed out a line she’d written at the top of one page: “PSLF projected forgiveness: ~$190,000 remaining in 2034.” Below it, she’d written a question mark.
“That’s the number I hold onto,” she said. “If it works — and I mean if — that’s almost $200,000 that just goes away. We’ve built our entire plan around that. I hope we didn’t make a mistake.”
Sitting across from her, I thought about the particular kind of stress that comes not from chaos but from waiting — from having done everything correctly and still not knowing if it will pay off. Aisha is not in crisis. She is not behind on anything. She is managing, precisely and methodically, a problem with a ten-year horizon. Whether the system delivers on its end of that equation is a question she cannot answer yet.
She picked up her notebook, tucked it into her bag, and said something I kept thinking about on the train home: “I just want to buy a condo and have a wedding and not have to do math about it.”
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