Essential SOAP Preparation Guide for IMGs in Emergency Medicine Residency

Understanding SOAP in the EM Match: What Every IMG Must Know

The Supplemental Offer and Acceptance Program (SOAP) is the NRMP’s structured process that replaces the old “scramble.” For an international medical graduate interested in emergency medicine residency, understanding SOAP early—before Match Week—is critical.

What is SOAP?

SOAP (Supplemental Offer and Acceptance Program) is a four‑day, time‑limited process during Match Week that allows eligible unmatched or partially matched applicants to:

• Apply to unfilled residency positions
• Communicate with programs under strict rules
• Receive up to four rounds of offers
• Secure a position before the Main Residency Match results are released

SOAP covers many specialties, and although categorical Emergency Medicine (EM) positions may be limited, EM‑related pathways (e.g., preliminary surgery, transitional year, internal medicine with later EM application) are often available and can serve as stepping stones.

Where SOAP Fits in the EM Match Timeline

For an IMG aiming for emergency medicine residency, SOAP is part of a longer journey:

1. ERAS Application Season (Sept–Jan)

   • Primary focus on EM programs (and possibly backup specialties).
   • Standardized letters, SLOEs, Step scores, clinical experience.

2. Interview Season (Oct–Jan)

   • Interviews with EM and backup programs.
   • Ongoing reassessment of competitiveness.

3. Rank Order List (Feb)

   • Rank EM and backup programs.
   • Consider risk tolerance for not over-ranking prelim/TY programs.

4. Match Week & SOAP (March)

   • Monday morning: You learn if you are matched, partially matched, or fully unmatched.
   • Monday–Thursday: SOAP occurs.
   • Friday: Main Match results released.

For many IMGs, SOAP is not an afterthought; it is a core component of a risk‑balanced EM residency strategy.

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Eligibility and Strategy: Is SOAP Part of Your IMG Residency Guide?

Before spending time on SOAP preparation, confirm you can participate.

SOAP Eligibility Basics for IMGs

You are generally SOAP‑eligible if:

• You registered for the NRMP Main Residency Match.
• You did not fully match (unmatched or partially matched).
• You submitted a certified rank list.
• You are ECFMG certified (or will be by the NRMP’s SOAP eligibility deadline).
• You have an active ERAS application for the current cycle.

You are not SOAP‑eligible if you:

• Did not register for the Match.
• Withdrew or were withdrawn from the Match.
• Matched to a full complement of positions (e.g., matched to a categorical EM position).
• Failed to meet ECFMG certification requirements by the deadline.

Action step:

• By January, verify your ECFMG status and check NRMP SOAP eligibility rules for the current year.

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Strategic Role of SOAP for EM‑Bound IMGs

Pure EM positions in SOAP may be sparse or highly competitive; however, EM‑focused IMGs can use SOAP to:

1. Secure a transitional year (TY) or preliminary year

   • Offers clinical exposure, US experience, and a salary while you reapply to EM.
   • Best if you can select rotations with EM exposure/critical care.

2. Enter a related core specialty (e.g., IM, FM, surgery prelim)

   • Some ultimately switch to EM after a year or two, but this path is complex.
   • You must be comfortable with the possibility of staying in that field.

3. Gain any accredited US training

   • Strengthens your CV and makes you more competitive for future attempts.
   • Avoid choices misaligned with your long‑term goals (e.g., highly niche fields you’re not ready to commit to).

Your SOAP strategy should be clearly defined well before Match Week:

• “If I go into SOAP, my Tier 1 target is: _______ (e.g., TY, prelim surgery).
• I will not apply to: _______ (e.g., specialties I would never pursue long‑term).”

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Pre–Match Week SOAP Preparation: Building Your Toolkit in Advance

You cannot predict SOAP, but you can prepare so you’re not starting from zero on Monday of Match Week. Successful SOAP preparation rests on four pillars:

1. Documents ready to adapt
2. Realistic target list and tiers
3. Technology, time, and support
4. Emotional readiness

1. Documents: Pre‑Draft Everything

During SOAP, there is almost no time to write new content from scratch. As an IMG in emergency medicine, build a SOAP‑ready document library months in advance.

Personal Statement Templates

Prepare short, adaptable personal statements for:

• Emergency Medicine (SOAP EM spots, combined or linked programs)
• Transitional Year (TY)
• Preliminary Surgery
• Preliminary Internal Medicine
• Family Medicine (if you would truly consider it)

Each should be:

• 400–700 words, concise and focused.
• Written to match the specialty’s priorities.
• Easy to tailor with program‑specific details.

Example structure (TY or prelim IM):

• 1–2 sentences: Acknowledge EM as your long‑term goal without undermining the program’s specialty.
• 1 short paragraph: Why this type of program (e.g., strong foundation in acute care, continuity of care).
• 1 paragraph: Your strengths (US clinical experience, EM rotations, language skills, teamwork).
• 1–2 sentences: How you plan to contribute and what you seek from the year.

Important:
Avoid sounding “temporary” or non‑committal. Programs know many IMGs see them as a stepping stone, but they still want candidates who will work hard, integrate into the team, and take the position seriously.

Letters of Recommendation (LoRs) and SLOEs

You cannot typically add new letters during SOAP, so ensure you already have:

• 2–3 strong EM letters/SLOEs.
• 1–2 non‑EM letters (IM, surgery, FM, etc.) if possible.
• At least one letter that speaks directly to your professionalism, reliability, and work ethic—traits valued across all specialties.

Before interview season ends:

• Politely remind letter writers to upload letters to ERAS early.
• Ask them to include comments about your adaptability and teamwork, which are relevant to multiple specialties.

CV & Experiences Section

Your ERAS application is your SOAP application. Review and update:

• Experience descriptions (focus on impact, responsibility, and outcomes).
• EM‑relevant activities (ED observing, research, EMS, global health).
• Any recent exams, courses, or certifications (ACLS, PALS, ATLS if available).

Make sure your entries highlight skills transferable to other specialties:

• Communication, triage, managing ambiguity, working night shifts, handling emergencies.

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2. Building a Target List and Tiers

SOAP limits how many programs you can apply to per round (usually up to 45 programs total across all specialties). You must be strategic.

Create a tiered target list before Match Week:

• Tier 1 – Most Preferred Pathways

  • Transitional year programs with EM exposure.
  • Preliminary surgery or internal medicine in hospitals with active EDs and ICUs.
  • Rare EM categorical spots if they exist.

• Tier 2 – Acceptable but Less Ideal

  • Categorical IM, FM, or other fields you might consider long‑term.
  • Consider locations you are comfortable living in.

• Tier 3 – Last Resort

  • Programs you would accept only if you have no other choice, but still could realistically see yourself completing.

Do not include any program you would absolutely refuse. Accepting an offer is binding. If you are not willing to move and train in that program for a year (or more), do not list it.

Action step:

• By February, generate a spreadsheet with:
  • Program name, specialty, state/city.
  • Type (TY, prelim, categorical).
  • Level of interest (1–3).
  • Website and notes (e.g., EM rotations, ICU exposure, IMG‑friendly history).

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3. Technology, Time, and Support Setup

SOAP moves quickly and is done largely online and via phone/video. Prepare:

• Reliable internet and backup (hotspot, second location in mind).
• Quiet workspace for potential same‑day or next‑day interviews.
• Updated professional voicemail greeting on your phone.
• Professional email checked frequently (and filters disabled so nothing goes to spam).

Inform close family and significant others about Match Week:

• Let them know you may be busy and stressed, and you may need quick advice.
• Ask one trusted advisor (mentor, EM attending, senior resident, dean) if they can be available by text/phone that week for rapid guidance.

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4. Emotional Preparation

SOAP week is emotionally intense, especially if you had your heart set on emergency medicine. Plan ahead:

• Recognize that not matching EM does not define your worth as a physician or your future success.
• Consider speaking with:
  • An EM mentor about realistic expectations.
  • A friend who recently went through SOAP.
• Decide in advance what success looks like for you:
  • Is it any US training?
  • Or only a certain specialty/pathway?

Having clear expectations will help you make decisions faster during the compressed SOAP timeline.

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Inside Match Week: Step‑by‑Step SOAP Preparation and Execution

Here is a typical outline of SOAP week from the IMG perspective, with focus on emergency medicine–focused pathways.

Monday Morning: You Learn You’re Unmatched or Partially Matched

At 10:00 AM ET (time may vary), the NRMP notifies you:

• Matched – You are done; SOAP does not apply.
• Partially Matched – You matched to an advanced program but not a preliminary year (or vice versa). You may participate in SOAP to complete your training plan.
• Unmatched – You can see the list of unfilled programs (if eligible) and participate in SOAP.

If you are SOAP‑eligible, do not panic. Instead:

1. Take 30–60 minutes to process emotions privately.
2. Re‑focus on the plan you created earlier.
3. Log into ERAS and NRMP to confirm SOAP access.

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Monday Midday: Reviewing Unfilled Programs and Prioritizing

Once the list of unfilled programs is released (for SOAP participants only):

1. Filter by Specialty and Type

   • Look immediately for:
     • Categorical EM (rare and high‑demand).
     • EM‑combined programs (e.g., EM–IM) if any.
     • Transitional year programs.
     • Preliminary IM, surgery, or other relevant prelims.
   • Mark those that accept IMGs (check websites, historical data, or online forums quickly).

2. Align with Your Tiered List

   • Match unfilled programs to the tiers you pre‑defined.
   • Add any new programs discovered from the list that fit your goals.

3. Decide on Scope

   • As an IMG in EM, it is usually wise to:
     • Apply broadly within your preferred categories (TY, prelim surgery/IM).
     • Avoid sending applications to fields you would never ultimately practice.

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Executing SOAP Applications: Messaging, Interviews, and Offers

During SOAP, you must navigate three main tasks: applying via ERAS, handling communication, and managing offers.

Submitting SOAP Applications Strategically

SOAP applications are submitted through ERAS, but your number of applications is limited (typically 45 total, though rules can change—verify each year).

Key points for EM‑bound IMGs:

• Start with your Tier 1 choices:
  • All available EM‑related spots (categorical EM, EM‑linked programs).
  • Strong TY and prelim programs in hospitals with EM and critical care exposure.
• If you still have application slots after Tier 1:
  • Move to Tier 2 programs that you could accept if needed.

For each program:

• Attach the most appropriate personal statement (EM, TY, prelim IM, etc.).
• Do not recycle an EM‑only statement for a family medicine program without careful editing. Programs can tell.

You cannot contact programs before they contact you during SOAP, unless explicitly allowed by NRMP rules. Review current guidelines each year to avoid violations.

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SOAP Interviews: Presenting Yourself as an EM‑Oriented IMG

SOAP interviews are often shorter and more focused than regular interviews, and may occur on the same day you apply.

Typical formats:

• 10–20 minute phone or video calls.
• Panel interviews with program director and faculty.
• Occasional informal conversations with residents or coordinators.

Core Story for EM‑Oriented IMGs

You need a consistent narrative that works across specialties:

1. Why EM?

   • Briefly share your passion for acute care, fast‑paced environments, and teamwork.
   • Mention prior EM experiences—rotations, research, volunteer work.

2. Why This Program/This Specialty During SOAP?

   • If TY or prelim:
     • “I am committed to a career in emergency medicine, and I believe a strong preliminary/transitional year in your program will provide critical foundations in inpatient medicine, ICU care, and procedural skills that will make me a better EM resident. I also know that regardless of where I match in the future, I will work as hard as any categorical resident and contribute fully to your team.”
   • If categorical IM/FM:
     • Be honest but respectful:
       “My long‑term interest has been in acute care and emergency medicine; however, I genuinely value the continuity of care and diagnostic depth in internal/family medicine. If I join your program, I am prepared to commit myself fully to becoming an excellent internist/family physician and a reliable team member.”

3. Why You (as an IMG)?

   • Highlight:
     • Diagnostic adaptability after training in a different health system.
     • Multilingual abilities.
     • Prior experience with high‑volume or resource‑limited settings.
     • Resilience: moving countries, passing USMLE, adjusting culturally.

4. What You Will Contribute This Year

   • Willingness to handle night shifts and ED consults.
   • Enthusiasm for teaching students.
   • Interest in QI or research projects.

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Common SOAP Interview Questions (and How to Frame Answers)

1. “Why do you think you did not match?”

   • Avoid blaming others or making excuses.
   • Reflect briefly and show insight:
     • “Emergency medicine is highly competitive, and as an IMG I may have been slightly below the Step score and SLOE profile of matched applicants. I also limited my applications geographically. I have reflected on this and am focused on continuing to grow clinically and academically wherever I train.”

2. “If you join us and receive an EM spot next year, will you leave?”

   • Be honest but professional:
     • “My ultimate goal is emergency medicine, but I also understand the importance of fulfilling contractual and professional obligations. If I match somewhere, I will respect the commitment I make. Regardless, in the year I spend with you, I will give 100% and function as a committed member of your team.”

3. “What are your strengths and weaknesses?”

   • Use examples from EM rotations (teamwork, rapid assessment, cross‑cultural communication).
   • For weaknesses, choose something you are actively working on (e.g., documentation efficiency, adapting to EMR systems).

4. “Why our program specifically?”

   • In SOAP, you may have little time to research, but at least review:
     • Location and patient population.
     • EM/ICU/trauma or acute care exposure.
     • Any IMG‑friendly indicators.

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Managing SOAP Offers and Rounds

SOAP usually has four offer rounds over two days. Offers appear in the NRMP system and must be accepted or rejected within a short window (e.g., 2 hours).

Key rules:

• You can hold only one offer at a time.
• Accepting an offer is binding; you are removed from further rounds.
• If you reject or let an offer expire, you may receive another later, but there is no guarantee.

Strategies for EM‑oriented IMGs:

• Clarify your priorities in advance. For example:
  1. Categorical EM (any location).
  2. Transitional year in hospitals with strong ED/ICU.
  3. Preliminary IM/surgery in institutions with EM residency.
  4. Categorical IM/FM in locations you could settle.
• During the offer window, ask:
  • “Can I see myself living and working here for at least 1 year?”
  • “Does this pathway keep reasonable options open for future EM applications or a satisfying career in another specialty?”

Discuss offers with a mentor if time allows, but be prepared to decide independently if needed.

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After SOAP: Next Steps for EM‑Focused IMGs

Regardless of your SOAP outcome, you must think beyond Match Week.

If You Matched into EM via SOAP

• Celebrate—but also:
  • Email the program director expressing gratitude and enthusiasm.
  • Stay engaged with EM literature, podcasts, and procedural skills.
  • Ask about orientation and any recommended prep (ATLS, ACLS renewals, etc.).

If You Matched into a TY or Prelim Position

This can be an excellent stepping stone for an IMG residency guide focused on emergency medicine.

Action items:

1. Speak to your program leadership early about:

   • EM rotations you can do during your year.
   • Opportunities to interact with EM faculty.
   • Research or QI projects relevant to acute care.

2. Strategize for reapplying to EM:

   • Plan for new or updated SLOEs during the year.
   • Ask EM attendings for targeted feedback to strengthen your next application.

3. Be an outstanding intern:

   • EM programs value strong evaluations from non‑EM rotations, especially ICU and inpatient services.

If You Matched into a Different Categorical Specialty

You face a significant decision:

• Commit fully to your new specialty, aiming to build a fulfilling career.
• Or, in rare cases, plan a carefully considered future switch to EM (which is complex and requires program support, open positions, and often another Match).

Either way, in your new program:

• Invest in building strong relationships and clinical skills.
• Keep a growth mindset—good physicians thrive in many specialties, not just EM.

If You Did Not Match at All (Post‑SOAP Unmatched)

This is painful, but your career is not over.

Next steps:

1. Meet with:

   • An EM program director, if possible.
   • An advisor experienced in IMG residency pathways.

2. Analyze your application:

   • USMLE scores and attempts.
   • Gaps in clinical experience or EM exposure.
   • Limited geographic spread or program list.
   • Weak SLOEs or letters.

3. Decide on a targeted improvement plan:

   • Additional U.S. clinical experience, especially in EM or acute care.
   • Research or QI with EM faculty.
   • Improving Step 3 timing or performance.
   • Consider reorienting toward a different specialty where your profile fits better.

4. Stay clinically active if possible:

   • Volunteer, research, or observerships.
   • Maintain clinical reasoning via study groups or case discussions.

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FAQs: SOAP Preparation for EM‑Oriented IMGs

1. As an international medical graduate, should I count on matching EM through SOAP?

No. EM positions in SOAP are usually few and extremely competitive. As an IMG, you should not rely on SOAP to secure an EM categorical spot. Instead, view SOAP as a way to:

• Obtain a transitional or preliminary year to strengthen your profile.
• Secure another acceptable training path while keeping future options open.

2. What is SOAP communication like? Can I email or call programs first?

During SOAP, contact rules are strict:

• You may not initiate contact with programs participating in SOAP before they reach out to you (unless explicitly allowed by current NRMP rules).
• Programs can contact you once they receive your application.
• Always check the updated NRMP SOAP communication rules each year; violations can jeopardize your candidacy.

3. How can I improve my chances as an IMG if I end up in SOAP for emergency medicine?

Actionable steps:

• Prepare SOAP‑appropriate personal statements early, tailored to EM, TY, and prelim specialties.
• Build a strong record of EM‑related experience: rotations, SLOEs, research, and QI.
• Keep your application flexible—highlight transferable skills that appeal to other areas (IM, surgery, FM).
• Have a clear tiered strategy for which types of positions you will prioritize.
• Enlist at least one trusted advisor who knows the EM match to help you rapidly process options during SOAP.

4. What is the difference between SOAP residency positions and the traditional Match?

Key differences:

• Timing:

  • Traditional Match: decisions made via rank lists before Match Week.
  • SOAP: occurs only during Match Week for unfilled positions.

• Process:

  • Traditional Match: preferences are expressed via rank lists and algorithm.
  • SOAP: you apply to a limited number of unfilled programs, programs review quickly, and offers go out in discrete rounds.

• Control:

  • Traditional Match: more structured, longer evaluation period, interviews months before ranking.
  • SOAP: highly compressed, limited communication, and quick decision‑making.

For an IMG targeting emergency medicine, the traditional match should be your primary goal, with SOAP serving as a carefully planned backup strategy within your overall residency roadmap.

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Preparing thoughtfully for SOAP does not mean expecting to fail; it means respecting how competitive emergency medicine is for international medical graduates and ensuring you have a clear, actionable plan for every possible outcome of Match Week. By building documents, strategy, and support before SOAP begins, you give yourself the best chance to secure a position that moves you forward—toward EM, or toward another satisfying pathway in U.S. residency training.