Mastering SOAP Preparation for DO Graduates in EM-IM Residency

Understanding SOAP for the DO Graduate Pursuing EM-IM

For a DO graduate targeting an Emergency Medicine-Internal Medicine (EM IM combined) pathway, the Supplemental Offer and Acceptance Program (SOAP) can feel high-stakes and confusing. You’ve invested years into your osteopathic medical education and now face the possibility of navigating the SOAP residency process, potentially after an unexpected unmatched result.

This article focuses specifically on SOAP preparation for DO graduates with primary interest in combined Emergency Medicine-Internal Medicine and related pathways. It will help you:

• Understand what SOAP is and how it works
• Prepare a specialty strategy tailored to EM-IM and to your profile as a DO graduate
• Optimize your documents and references before Match Week
• Execute a disciplined, realistic application plan during SOAP
• Make smart decisions under time pressure—and position yourself for future success, even if you pivot specialties

We’ll also clarify “what is SOAP,” strategic options if EM-IM combined programs are limited, and how to leverage your osteopathic background as an advantage rather than a barrier.

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What Is SOAP and Why It Matters for EM-IM–Focused DO Graduates

What Is SOAP?

SOAP (Supplemental Offer and Acceptance Program) is an NRMP-managed process that allows unmatched or partially matched applicants to apply to unfilled residency positions in a structured, time-limited way during Match Week.

Key elements of SOAP residency:

• Takes place the week of the Main Residency Match
• Only applicants who are SOAP-eligible (verified by NRMP and ERAS) can participate
• You may submit up to 45 applications total during SOAP
• Programs review applications, conduct very rapid interviews (often virtual or phone), then submit preference lists
• Offers go out in several rounds; you can accept, reject, or let offers expire (with rules and consequences)

For a DO graduate, especially one targeting EM IM combined or emergency medicine internal medicine adjacent pathways, SOAP is:

• A second chance to secure a categorical or preliminary position
• An opportunity to pivot to related fields (e.g., EM only, IM only, transitional, prelim medicine)
• A test of your preparation, flexibility, and clarity of career goals under pressure

SOAP Eligibility Basics for DO Graduates

To participate in SOAP, you must:

• Be registered for the NRMP Match
• Have no active Match, or be partially matched (e.g., matched to advanced only or prelim only and still need the other component)
• Be ERAS-registered and have your documents uploaded and certified
• Have no binding match commitment that conflicts with accepting a SOAP offer

Be proactive in confirming SOAP eligibility with:

• NRMP (via R3 system)
• Your medical school’s dean’s office or Student Affairs
• ERAS support (for technical/document readiness)

If you’re an international DO (e.g., US citizen DO graduate abroad), confirm that all exam requirements and credentialing are complete by early February.

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Pre-Match SOAP Preparation: Building a Flexible EM-IM–Focused Plan

SOAP is unforgiving if you arrive unprepared. The strongest advantage you can give yourself is to complete SOAP preparation 4–6 weeks before Match Week, even if you feel confident about matching in EM-IM.

1. Clarify Your Priority Hierarchy: EM-IM vs. EM vs. IM

Before SOAP begins, decide—honestly—how you rank your career preferences:

1. Top choice: EM IM combined (emergency medicine internal medicine)
2. Second tier: Pure Emergency Medicine or categorical Internal Medicine
3. Third tier: Transitional year, preliminary Internal Medicine, or other related fields
4. Fourth tier: Any position that keeps options open (e.g., prelim in another specialty, off-cycle plans)

For most DO graduates serious about EM-IM, the reality is:

• EM-IM combined programs are few in number and competitive
• Many EM-IM programs will be fully filled after the initial match and will not appear in SOAP
• You must be ready to pivot quickly to EM-only, IM-only, or a well-chosen alternative pathway

Action step:
Write a one-page “SOAP priorities document” listing:

• Must-have: positions you would gladly accept (e.g., categorical IM at an academic center with strong ED exposure)
• Acceptable alternatives: e.g., strong prelim IM year in a hospital with an EM residency
• Last-resort: positions you’ll consider only if nothing else is available (be honest)

Keep this document accessible and discuss it with a trusted advisor or mentor before Match Week.

2. Audit Your Application Through an EM-IM Lens

Review your residency application as an EM-IM–focused DO graduate:

• Scores and exams:
  • COMLEX Level 1/2/3 and, if taken, USMLE Step 1/2
  • If your scores are modest or there are failures/repeats, expect fewer EM or EM-IM openings and plan a more IM-heavy SOAP strategy
• Clinical experiences:
  • EM rotations (especially ACGME academic settings)
  • IM sub-internships or acting internships (inpatient heavy)
  • Combined exposure: ED time with admissions follow-up on the ward or ICU rotations
• Letters of recommendation:
  • At least one EM letter (ideally from a program director or clerkship director)
  • At least one IM letter
  • A strong osteopathic physician (DO) letter can be a plus, particularly at DO-friendly institutions
• Personal statement:
  • Does it clearly articulate why combined emergency medicine internal medicine fits your long-term career goals?
  • Do you emphasize adaptability, systems thinking, and continuity from ED to inpatient care?

Identify potential weaknesses that might impact your ability to match EM-IM:

• Limited EM exposure or lukewarm letters
• USMLE not taken and some EM programs being USMLE-prioritized
• Gaps, leaves, or professionalism issues

Not every gap can be fixed pre-SOAP—but you can prepare explanations and adjust your strategy accordingly.

3. Create SOAP-Ready Document Variants

You must assume that during SOAP you might apply to:

• EM IM combined (if any spots appear)
• Categorical EM
• Categorical IM
• Transitional year or preliminary medicine

Prepare multiple tailored documents before Match Week:

a. Multiple Personal Statements

• EM-IM combined personal statement
  • Emphasize: dual interests, seamless ED-to-ward care, complex chronic disease in acute crises, systems-based practice
• EM-only personal statement
  • Highlight: resuscitation skills, rapid decision-making, ED flow, procedural interests
• IM-only personal statement
  • Emphasize: longitudinal patient relationships, diagnostic reasoning, chronic disease management, inpatient medicine skills
• Prelim/Transitional year personal statement
  • Focus: desire for a strong clinical foundation, flexibility, and preparation for a future career in EM/IM

Name them clearly in ERAS and be meticulous in assigning the correct statement to each specialty/program.

b. CV and Experiences

Ensure your ERAS experiences are structured to highlight:

• Leadership roles (e.g., EM interest groups, osteopathic student associations)
• Emergency/acute care roles (EMS ride-alongs, ED tech, research in EM)
• Internal medicine depth (ward responsibilities, quality improvement projects, chronic disease clinics)

You will not have time during SOAP to re-structure your CV; finalize it now.

c. Letters of Recommendation Strategy

You cannot upload new letters mid-SOAP. But you can pre-prepare:

• A set of EM letters (at least 1–2)
• A set of IM letters (at least 1–2)
• If possible, a combined perspective (e.g., a faculty who works in ED and wards or a dual-trained EM-IM mentor)

In ERAS, you can assign different combinations of letters to different programs during SOAP. Plan assignments in advance:

• EM-IM: 1 EM, 1 IM, 1 “bridging” combined or your strongest overall
• EM-only: 2 EM + 1 strong general letter
• IM-only: 2 IM + 1 strong general letter

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Strategy on Match Week: Executing a Smart SOAP Residency Plan

Once you learn you are unmatched or partially matched on Monday of Match Week, you will have only hours to shift from shock to action. A clear, pre-made SOAP preparation plan is critical.

1. Interpreting the Unfilled List for an EM-IM–Oriented DO

When the list of unfilled programs becomes available to SOAP-eligible applicants:

1. Search systematically:

   • First, filter for EM-IM combined (Emergency Medicine-Internal Medicine) programs. Many years, there may be few or no EM-IM spots, but you must check.
   • Next, search EM-only and IM-only positions.
   • Also check transitional year and prelim medicine positions at institutions with EM or IM residencies.

2. Assess DO-friendliness quickly:

   • Look at program histories: Has the program previously taken DO graduates? (Check current residents on their website if time permits.)
   • Consider states/regions with historically higher DO representation (e.g., Midwest, certain community-based programs).

3. Group programs into tiers:

   • Tier 1: Highly desirable, realistic for your profile (e.g., DO-friendly IM programs, EM at institutions with history of DOs, any EM-IM combined if available)
   • Tier 2: Acceptable programs with good training that you would realistically attend
   • Tier 3: Programs you’ll only apply to if you are not reaching 45 applications with Tiers 1 and 2

You must be ruthless and time-efficient—your emotions cannot drive your choices at this stage.

2. Choosing How to Spend Your 45 SOAP Applications

A common mistake is to over-concentrate on a single specialty during SOAP (e.g., all 45 to EM) or spread yourself too thin across unrelated specialties. For an EM-IM–focused DO, a balanced template might look like:

Example allocation strategy (adjust to your situation):

• 10–15 applications: EM-IM combined and EM-only positions where your application is competitive
• 20–25 applications: Categorical Internal Medicine at DO-friendly or mid-tier academic/community programs
• 5–10 applications: Transitional year and prelim medicine at programs with strong EM/IM presence

Factors affecting your personal allocation:

• Strong EM letters and high COMLEX/USMLE: you can lean more toward EM
• Strong IM rotations and research: lean slightly more to IM
• Below-average scores or red flags: weigh more toward categorical IM and prelim options, where there may be more volume

Critical principle:
Every program you apply to in SOAP should be a place you are genuinely willing to train. Do not “waste” applications on institutions you would never attend.

3. Tailoring Your SOAP Applications Under Time Pressure

Once you have your list:

1. Assign the correct personal statement:

   • EM → EM statement
   • IM → IM statement
   • Transitional/prelim → prelim/TY statement
   • Any EM-IM combined → EM-IM statement

2. Assign letters strategically:

   • Double check before final submission—this is a common error in SOAP.

3. Program-specific communication (if allowed):
   Some institutions may allow brief emails to the program via a coordinator or a SOAP-designated contact. If permitted by your school’s policy:

   • Keep messages short: 4–6 sentences
   • Emphasize:
     • DO training and osteopathic principles (holistic, systems-focused, hands-on exam skills)
     • Clear interest in EM/IM or acute care
     • One or two specifics about their program that align with your goals

Avoid mass, generic emails. Focus on your Tier 1 programs.

4. Preparing for Rapid SOAP Interviews

SOAP interviews are often:

• Short (10–20 minutes)
• Scheduled with minimal notice
• Conducted by phone or virtual platform
• Focused on “fit” and your readiness to start in July

For a DO graduate with EM-IM aspirations, you should be prepared to answer:

• “You applied to EM-IM originally; why are you interested in our categorical IM (or EM) program now?”
• “How do you see yourself using both acute care and longitudinal skills if you match here?”
• “Tell me about a time you made a rapid, high-stakes clinical decision and what you learned.”
• “Why were you unsuccessful in the main Match, and what have you learned from that process?”

Have clear, honest but confident responses ready:

Example framing:

“I initially ranked multiple EM-IM combined programs because I’m passionate about the interface between emergency care and complex inpatient medicine. Unfortunately, these programs are few and highly competitive. Through SOAP, I’m looking for a program where I can still develop strong acute care and inpatient skills. Your Internal Medicine program, particularly with its robust ICU and ED consult experience, aligns with that goal. I see this as a direct path to becoming a strong acute care internist who can work effectively at that ED–inpatient interface.”

Emphasize:

• Resilience and growth mindset
• Appreciation for the opportunity
• Realistic understanding of the program’s demands

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Leveraging Your DO Background During SOAP

As a DO graduate in the osteopathic residency match ecosystem and now the broader ACGME landscape, you bring distinct value. During SOAP, you must articulate it clearly and succinctly.

1. Highlight Osteopathic Strengths Relevant to EM-IM

In your statements and interviews, integrate:

• Holistic, systems-based perspective:
  • EM-IM combined training thrives on physicians who see connections between acute presentations and chronic disease trajectories.
• Hands-on physical exam and procedural comfort:
  • ED and IM wards both rely on strong bedside skills; DO education often emphasizes this vigorously.
• Adaptability in diverse settings:
  • Many osteopathic schools have strong community and rural rotations; this translates well to busy EDs and broad-spectrum IM inpatient services.

Avoid generic “I like holistic medicine” statements; be specific:

“My osteopathic training emphasized not just the acute chief complaint, but the patient’s functional status, social supports, and chronic illness trajectory. On my EM rotations, this allowed me to think beyond disposition from the ED—anticipating which patients would decompensate on the floor, need ICU-level care, or benefit from early palliative involvement.”

2. Address Common DO Concerns During SOAP

Some DO graduates worry about being disadvantaged relative to MDs, especially in EM or combined programs. In SOAP:

• Remember that many unfilled positions are in DO-friendly programs or regions
• Many program directors value work ethic, teachability, and professionalism over school letters alone
• You cannot change your degree; you can control your narrative, preparation, and professionalism

If asked directly about being a DO:

“I’m proud of my DO training. It gave me a strong foundation in clinical reasoning, patient-centered care, and hands-on skills. In my EM and IM rotations at ACGME institutions, I’ve worked alongside MD peers at the same level of responsibility and performance, and I’m confident I can integrate seamlessly into your program’s team.”

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If You Don’t Secure an EM-IM–Aligned Position in SOAP

Even with excellent SOAP preparation, some applicants will not secure a SOAP residency position. For an EM-IM–focused DO graduate, this is painful but not the end of your career.

1. Debrief Objectively

After SOAP concludes:

• Meet with:
  • Your Dean or Student Affairs advisor
  • An EM (or EM-IM, if available) mentor
  • An Internal Medicine mentor

Ask for honest feedback on:

• Scores and exam history
• Strength of letters
• Interview skills and professionalism
• Realistic competitiveness for EM, EM-IM, and IM in future cycles

2. Consider Strategic Gap-Year Options

Depending on feedback and resources, consider:

• Clinical research in EM or IM at an academic center
• Non-ACGME fellowships or preliminary training (some hospitals offer clinical roles to unmatched grads)
• Additional rotations (sub-internships) to obtain stronger letters and updated evaluations
• Exam remediation or retakes if failures significantly impacted you

A gap year can be reframed next cycle as:

“I took a year to strengthen my clinical and academic foundation, focusing on research in emergency care transitions to inpatient medicine and gaining additional supervised clinical experience. That time confirmed my commitment to EM/IM and significantly improved my readiness for residency.”

3. Revisiting Your Specialty Strategy

After a SOAP miss, you may need to broaden your future focus:

• Target categorical IM more heavily, with EM electives and future EM fellowship plans (e.g., critical care, hospitalist in ED/observation units)
• Consider a long-term path where IM training leads to significant ED or acute care practice in specific health systems
• For some, pivoting fully to IM (or another field) may provide a more stable and achievable route

The key is to maintain professional growth and demonstrate persistent, focused commitment in your next application cycle.

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Frequently Asked Questions (FAQ)

1. How different is SOAP preparation for EM-IM combined programs compared to standard EM or IM?
For EM-IM combined, your SOAP preparation must assume very few or no EM-IM spots will be open. You should still prepare a specific EM-IM personal statement and be ready if an opening appears. However, your primary SOAP strategy must realistically focus on EM-only and IM-only positions (and possibly prelim/TY positions) that still align with your long-term interest in the ED–inpatient interface.

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2. As a DO graduate, should I take USMLE if I’m primarily interested in EM-IM and EM?
If you are early enough in training, taking USMLE Step 2 can broaden your opportunities, especially in EM. However, by SOAP time, your exams are already completed. The immediate SOAP preparation should focus on presenting your existing COMLEX (and USMLE, if taken) scores and experiences in the strongest light. For future cycles, if you have not taken USMLE and your advisors believe your COMLEX performance is strong, you may be competitive without it at many DO-friendly EM and IM programs.

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3. What is SOAP preparation I should absolutely complete before Match Week?
For a DO graduate targeting emergency medicine internal medicine, your non-negotiable SOAP preparation list includes:

• Multiple personal statements (EM-IM, EM, IM, prelim/TY) uploaded and ready
• A clear list of your preferred backup specialties and acceptable alternatives
• Pre-planned letter of recommendation assignments for EM vs IM vs prelim/TY
• A one-page “SOAP priorities” document guiding how you’ll use your 45 applications
• Practiced answers to questions about not matching, your DO background, and your long-term EM/IM goals

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4. If I SOAP into categorical Internal Medicine, can I still build a career similar to EM-IM?
Yes—while it won’t be identical to formal EM-IM combined training, you can move toward a career that blends acute and inpatient care:

• Choose an IM program with strong ICU, ED consult, and hospitalist training
• Seek elective time in the ED, critical care, and observation units
• Engage in quality improvement and research at the ED–inpatient interface (e.g., sepsis care, admission flow, early discharge planning)
• After residency, pursue roles in hospital medicine with significant ED collaboration or critical care pathways

SOAP can place you in a solid IM program that still supports your long-term interest in acute and emergency care.

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By approaching SOAP with a clear strategy, realistic expectations, and well-crafted materials tuned to EM-IM and related pathways, you maximize your chances of landing a training position that keeps your emergency medicine internal medicine ambitions alive—and sets you up for a resilient, adaptable career as a DO graduate in acute care medicine.