Ultimate IMG Residency Guide: SOAP Preparation for Med-Psych Success

Understanding SOAP: What It Is and Why It Matters for IMGs in Med-Psych

The Supplemental Offer and Acceptance Program (SOAP) is the structured process that replaces the old “Scramble” during Match Week. For an international medical graduate, especially someone targeting a competitive and nuanced field like Medicine-Psychiatry, strong SOAP preparation can be the difference between securing a residency position and going unmatched.

Before you can prepare well, you need to understand:

What is SOAP?

SOAP is a four-day process run by NRMP during Match Week that allows eligible unmatched or partially matched applicants to apply to unfilled residency positions through ERAS.

Key features:

• You can apply to a maximum of 45 programs during SOAP.
• Applications are sent only via ERAS, not by email or phone.
• There are rounds of offers from programs to applicants:
  • Monday: You learn you are unmatched or partially matched.
  • Monday–Thursday: Multiple SOAP offer rounds occur.
  • Thursday afternoon: SOAP ends; remaining positions become visible for post-SOAP communication.

For an IMG, especially one interested in medicine psychiatry combined (med psych residency) or planning to use SOAP to back up with categorical Internal Medicine or Psychiatry, a clear SOAP strategy is essential.

Why SOAP Is Especially Important for IMGs in Medicine-Psychiatry

Medicine-Psychiatry programs are:

• Few in number and highly selective.
• Looking for clear, dual interest in both Internal Medicine and Psychiatry.
• Often favoring applicants with strong communication skills, adaptability, and resilience.

As an international medical graduate:

• You may face additional barriers: visa needs, less familiar schools, different healthcare systems, and potential bias.
• If you did not match to Medicine-Psychiatry or categorical programs, SOAP offers a structured second chance.

A thoughtful IMG residency guide for SOAP in Med-Psych doesn’t only teach you logistics; it helps you reframe your entire application strategy around flexibility: targeting categorical Internal Medicine, categorical Psychiatry, preliminary Internal Medicine, transitional year, or even less competitive specialties if needed.

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Pre-Match Week: Building a SOAP-Ready Application

The strongest SOAP strategy happens months before Match Week. You cannot meaningfully rewrite your story during those few stressful days. You prepare now.

1. Clarify Your Strategic Priorities

Before you think about SOAP preparation, decide realistically:

• Is your top long-term goal:
  • Practicing primarily as an internist with strong psychiatric skills?
  • Practicing primarily as a psychiatrist with medical expertise?
  • Doing a medicine psychiatry combined program if possible, but otherwise happy with categorical Medicine or Psychiatry?

Your priority ranking might look like:

1. Medicine-Psychiatry combined (if available to you during regular Match)
2. Categorical Internal Medicine and/or Psychiatry
3. Preliminary Internal Medicine, Transitional Year
4. Other specialties consistent with your background and visa constraints

This priority list determines how you:

• Write your personal statement(s)
• Arrange your letters of recommendation (LORs)
• Decide which programs to target during SOAP

2. Optimize ERAS Now for SOAP Flexibility

ERAS is the engine that drives SOAP residency applications. During SOAP, you will not have the luxury of rebuilding your application. Instead, you must already have:

Multiple Personal Statements Prepared

At minimum, for an IMG aiming at med psych residency, prepare:

1. Medicine-Psychiatry–Focused PS

   • Explains your dual interest clearly.
   • Uses integrated clinical scenarios (e.g., a patient with uncontrolled diabetes and major depression).
   • Highlights experiences bridging medicine and psychiatry (consult-liaison, psychosomatic medicine, primary care mental health).

2. Internal Medicine–Focused PS

   • Emphasizes complex medical decision-making, continuity of care, inpatient and outpatient experiences.
   • Mentions interest in mental health but keeps the main focus on Internal Medicine.

3. Psychiatry–Focused PS

   • Emphasizes your understanding of psychiatric pathology, therapeutic communication, biopsychosocial perspective.
   • Mentions your comfort with medical complexity as a strength without overshadowing your psychiatric interest.

If SOAP forces you to pivot—for example, from medicine psychiatry combined to strictly Internal Medicine or Psychiatry—you’re already prepared to assign the right statement to the right program quickly.

Letters of Recommendation (LORs) with Versatility

Aim for 3–4 high-quality LORs well before Rank Order List certification:

• At least one letter from Internal Medicine faculty.
• At least one from Psychiatry faculty.
• Ideally one from a setting that integrates both (CL psychiatry rotation, inpatient medicine service dealing with severe mental illness, primary care behavioral health, etc.).

Structure:

• 2 letters can be used across IM and Psych (e.g., from a CL psychiatrist and a hospitalist praising your holistic approach).
• 1 IM-specific and 1 Psych-specific letter.

You won’t change the letters during SOAP, but you can choose which 3–4 to assign strategically to each program type.

Update and SOAP-Proof Your CV

Ensure your CV is:

• Error-free, concise, and updated with:
  • Most recent US clinical experience (USCE) or observerships.
  • QI projects, case reports, or research related to medicine, psychiatry, or both.
  • Volunteer work showing communication skills, teamwork, and cultural competence.

Highlight:

• Any case management or liaison experiences between medicine and psychiatry.
• Work with suicidal patients, substance use disorders, chronic disease with mental health comorbidities.
• Experiences that show adaptability and resilience—critical qualities programs look for in SOAP.

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Week Before Match: Tactical SOAP Preparation

The week or two before Match Week is when you move from strategic setup to tactical readiness.

1. Understand SOAP Eligibility and Logistics

To participate in SOAP, you must:

• Register for NRMP and certify a rank order list (or be withdrawn prior to certification under specific conditions).
• Be eligible for US GME (e.g., ECFMG certified before the NRMP deadline for IMGs).
• Remain unmatched or partially matched on Monday of Match Week.

Know your status:

• Unmatched: No PGY-1 position.
• Partially matched: Matched to an advanced position but not a PGY-1 spot (or matched to one track but missing another required component).

If you are uncertain about your certification or visa status, clarify it before February each year, not during SOAP week.

2. Tools and Systems to Prepare

During SOAP, time is compressed. You will need to make rapid but thoughtful decisions. Set up:

A SOAP Spreadsheet

Create columns such as:

• Program Name
• Specialty (IM, Psych, Med-Psych, TY, Prelim IM, etc.)
• Location
• Visa status (sponsors J-1? H-1B? none?)
• IMG-friendly (historically matched IMGs?)
• Your interest level (High/Medium/Low)
• Notes (hospital type, patient population, any alumni present, etc.)
• Whether you’ve applied during SOAP
• Interview time and contact info

You can fill some of this in advance with:

• A list of all Medicine-Psychiatry programs and general IM/Psych programs you like.
• Public information on visa sponsorship and IMG friendliness.

During SOAP, when the list of unfilled programs appears, you’ll cross-check rapidly and prioritize.

Pre-Drafted Communication Templates (Not for Direct Solicitation During SOAP)

You cannot contact programs to solicit positions during SOAP unless they reach out to you through approved channels. However:

• You will need post-SOAP emails if you remain unmatched.
• You may also need polite, professional responses to program-initiated contact during SOAP (e.g., inviting for a brief virtual meeting).

Prepare templates for:

• Brief thank-you email after a SOAP interview or phone/Zoom conversation.
• Post-SOAP outreach email for open positions.

3. Mental Preparation and Support Structure

SOAP can be emotionally brutal, especially for an IMG who may already feel isolated.

Plan:

• A support system: family, mentors, co-applicants, or IMG support groups.
• Time blocks for:
  • Reviewing programs
  • Attending SOAP interviews
  • Rest and meals
• A strategy for staying calm on Monday when you receive unmatched/partially matched results.

Remind yourself:

• Not matching initially does not equal failure; many excellent residents and attendings found their path through SOAP.
• Your goal is to secure solid training, even if the path is non-linear (e.g., starting with categorical IM and later adding Psych via fellowship or consultation-liaison work).

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SOAP Week Day-by-Day for the IMG Targeting Med-Psych

Here is a structured timeline and approach:

Monday: Results and Reality Check

You learn your status at 11:00 AM ET (time may vary slightly by year). If you are unmatched or partially matched, you become SOAP-eligible.

Steps:

1. Process Emotion Quickly but Honestly

   • Take 30–60 minutes away from the computer.
   • Talk to someone supportive.
   • Then return to a professional mindset: “Now I am problem-solving.”

2. Access the List of Unfilled Programs

   • This list appears in the NRMP/ERAS systems.
   • Filter by:
     • Specialty: Internal Medicine, Psychiatry, Transitional Year, Preliminary Internal Medicine, occasionally Med-Psych if available.
     • Visa policies.
     • Geographic constraints (if any).

3. Apply Your Priority Strategy

   • If there are Medicine-Psychiatry combined positions open, review them first:
     • Are they IMG-friendly?
     • Do they sponsor your visa?
   • Next, evaluate:
     • Categorical Internal Medicine programs that might value your psych interest.
     • Categorical Psychiatry programs that appreciate your medical background.
     • Transitional Year or Prelim IM if you have an advanced position or want a foothold in the system.

4. Assign the Correct Personal Statements and LORs

   • For IM programs: Use IM PS + IM-heavy LOR combination.
   • For Psych programs: Use Psych PS + Psych-supportive letters.
   • For any rare available Med-Psych spots: Use your combined PS and mix of IM and Psych letters that demonstrate integrated interest.

You have a 45-program limit under SOAP. Use it strategically, not randomly.

Tuesday to Thursday: Interviews, Offers, and Decisions

During SOAP:

• Programs may:
  • Review your application.
  • Conduct brief phone or video interviews.
  • Make offers during the official rounds.

Preparing for SOAP Interviews as an IMG in Med-Psych

Interview questions focus on:

• Your story: Why Internal Medicine? Why Psychiatry? Why (or why not) combined?
• Why you think you did not match initially.
• What you have done to address weaknesses.
• How you handle stress and setbacks.

Sample tailored responses:

Q: “You applied to Medicine-Psychiatry originally. Why are you now applying only to Internal Medicine?”

Your answer might include:

• Your genuine enthusiasm for Internal Medicine, independent of combined training.
• Recognition that strong internal medicine training will still allow you to work closely with psychiatric patients (e.g., medically ill patients with severe mental illness, addiction medicine, psychosomatic medicine).
• Gratitude for any opportunity to train and grow in this field.

Q: “As an international medical graduate, what challenges have you faced, and how will you adapt to our system?”

Emphasize:

• Learning a new healthcare system and EMR.
• Improving your communication in American medical English.
• Using feedback from USCE, observerships, or electives.
• Demonstrated adaptability (e.g., moving countries, learning new protocols).

Avoiding Common Errors During SOAP

Do not:

• Panic-apply to 45 random programs with no consideration of visa, specialty fit, or competitiveness.
• Appear bitter or blameful when asked why you did not match.
• Overshare personal details; stay professional and focused on growth and readiness.
• Contact programs outside permitted channels or violate NRMP rules.

Do:

• Keep your schedule relatively open Tuesday–Thursday for interviews.
• Check your email and ERAS portal frequently, but not obsessively.
• Maintain a calm, polite, and responsive demeanor with all program staff.

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Post-SOAP: If You Match vs. If You Don’t

If You Secure a Position Through SOAP

Whether you match to:

• Categorical Internal Medicine
• Categorical Psychiatry
• Transitional Year / Preliminary Internal Medicine
• Rarely, a Medicine-Psychiatry combined spot during SOAP (uncommon but theoretically possible)

Your next steps are:

1. Accept the Offer Promptly

   • Once you accept, it is binding.
   • Do not attempt to negotiate with other programs or reverse the decision.

2. Shift Mindset from “Backup” to “Primary Path”

   • Avoid treating SOAP positions as second-class; programs are sensitive to this.
   • Tell yourself: “This is now my training home. I will make the most of it.”

3. Leverage Training Toward Your Med-Psych Interests

   • In IM: Seek rotations dealing with psychiatric comorbidities, addiction, CL services, outpatient clinics with mental health integration.
   • In Psych: Focus on medically complex patients, somatic symptom disorders, addiction, and close collaboration with medicine services.
   • Engage in QI and research projects that highlight bridging medicine and psychiatry.

This allows you to remain aligned with your long-term identity—even if you did not end up in a formal med psych residency.

If You Do Not Secure a Position Through SOAP

It is painful but not the end of your journey. An honest post-mortem is crucial.

1. Analyze What Happened

Consider:

• Were your USMLE scores below typical cutoffs?
• Were you missing recent USCE?
• Did your personal statements or LORs not clearly support your chosen specialties?
• Were your geographic or visa constraints too restrictive?
• Did you aim too high without including enough IMG-friendly programs?

Seek feedback from:

• Trusted faculty mentors (IM and Psych).
• IMG advisors or match consultants, if accessible.
• Program coordinators you have a relationship with (some may offer informal feedback).

2. Strengthen Your Profile for the Next Cycle

If you still desire medicine psychiatry combined, or at least a career combining both fields:

• Pursue research or clinical work related to:
  • Addiction medicine
  • Consultation-liaison psychiatry
  • Primary care–behavioral health integration
• Gain additional USCE if possible, in both IM and Psych.
• Improve any deficits:
  • Retake language proficiency exams if required.
  • Refine communication skills through practice and simulation.

Rebuild your application:

• Update PS to reflect growth, reflection on not matching, and concrete steps you’ve taken.
• Secure new LORs from US supervisors.
• Apply more broadly and more strategically next cycle.

3. Stay Professionally Active

Avoid gaps. Maintain:

• Clinical involvement (even in your home country if US opportunities are limited).
• Academic productivity: case reports, literature reviews, poster presentations.
• Continuing education: online CME in both internal medicine and psychiatry topics.

This sustained engagement demonstrates commitment and resilience—qualities valued by program directors.

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Practical Tips Tailored to IMGs Interested in Med-Psych

To summarize the most actionable advice:

1. Start SOAP preparation months early

   • Multiple PS versions: Med-Psych, IM-only, Psych-only.
   • Flexible LOR strategy supporting both specialties.
   • Up-to-date CV emphasizing integrated care experiences.

2. Know your answer to “Why Medicine-Psychiatry?”

   • Be ready to translate that answer into enthusiasm for either IM or Psych alone.
   • Use clinical stories that show how you think across both domains.

3. Target IMG-friendly environments

   • Research programs with past IMGs, J-1 or H-1B support, and a history of training diverse residents.
   • Use your 45 SOAP slots carefully: quality over blind quantity.

4. Understand what is SOAP and how it works

   • Familiarity with the rules helps you avoid missteps.
   • The best SOAP residency strategy combines rule awareness, speed, and thoughtful targeting.

5. Control what you can: professionalism, responsiveness, and attitude

   • You cannot change your scores during SOAP week, but you can:
     • Answer calls promptly.
     • Show maturity in discussing not matching.
     • Convey enthusiasm and humility.

6. View every path as a potential route back to Med-Psych themes

   • In IM: pursue CL consults, addiction medicine, psychosomatic disease.
   • In Psych: pursue medically complex populations, integrated care, collaborative clinics.
   • Ultimately, your daily practice can embody Medicine + Psychiatry even without a dual-board program.

For an international medical graduate, this IMG residency guide to SOAP preparation in Medicine-Psychiatry aims to give you not just information, but a realistic, structured plan. You are not powerless during SOAP; with preparation, you can turn a stressful week into a genuine second chance.

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FAQ: SOAP Preparation for IMGs in Medicine-Psychiatry

1. Can I still pursue a Medicine-Psychiatry career if I don’t match into a combined program?
Yes. Many physicians build a Med-Psych–style career through categorical Internal Medicine or Psychiatry training. For example:

• IM → fellowship in Consultation-Liaison Psychiatry (with a second residency later), or practice in settings with high psychiatric comorbidity.
• Psych → focus on medically complex patients, CL services, and integrated care clinics. Your day-to-day clinical focus can embody both fields, even without formal dual training.

2. What should my SOAP strategy be if there are no Medicine-Psychiatry spots available?
Prioritize based on your long-term identity:

• If you lean toward internal medicine, use your IM-focused PS and LORs to target categorical IM and prelim IM/TY spots.
• If you lean toward psychiatry, use your Psych-focused materials to target categorical Psych. In both cases, highlight your dual interest as a strength (comfort managing complex comorbid conditions, communication skills, holistic approach).

3. As an IMG, how important is visa sponsorship during SOAP?
Critical. You must be realistic: applying to programs that do not sponsor your visa wastes one of your 45 limited SOAP slots. Before SOAP week, research:

• Which programs sponsor J-1 and/or H-1B.
• Whether your visa status aligns with their policies. Prioritize programs where your visa needs can actually be met.

4. How do I explain in SOAP interviews why I didn’t match without sounding negative?
Be honest, brief, and focused on growth:

• Acknowledge likely factors (e.g., scores below average, late USCE, limited geographic flexibility).
• Emphasize what you’ve learned and how you’ve improved (better clinical experience, stronger communication, more realistic targeting).
• Express gratitude for the chance to interview and highlight your readiness to contribute.

Avoid blaming others or the system. Programs want to see maturity, self-awareness, and resilience—especially in Medicine-Psychiatry–minded applicants who will care for highly complex patients.