Mastering SOAP Preparation for DO Graduates in Internal Medicine Residency

Preparing for the Supplemental Offer and Acceptance Program (SOAP) as a DO graduate pursuing internal medicine residency is stressful—but it’s also manageable with the right strategy. The SOAP window is short, highly structured, and emotionally intense. Your goal is to convert that compressed time into organized, high-yield action that maximizes your chances of matching into an internal medicine residency.

This guide walks you through SOAP preparation specifically for DO graduates targeting internal medicine, including timelines, strategy, documents, communication etiquette, and mindset.

---

Understanding SOAP: What It Is and Why It Matters for DO Graduates

The first step in SOAP preparation is knowing exactly what is SOAP and how it fits into the NRMP Match process.

What Is SOAP?

The Supplemental Offer and Acceptance Program (SOAP) is a structured process run by NRMP that helps unmatched or partially matched applicants fill unfilled residency positions in accredited programs after the main Match rank order list results are released.

Key points:

• It occurs during Match Week (Monday–Thursday).
• It is not a free-for-all scramble; it’s a regulated, timed, and online process.
• Applicants apply only through ERAS to programs with unfilled positions listed in the NRMP List of Unfilled Programs.
• Programs review applications, conduct brief interviews (often virtual), and send preference lists to NRMP.
• NRMP runs up to four SOAP rounds, making offers through the system.

For a DO graduate, the SOAP can be a critical second opportunity, especially for internal medicine residency (IM) where there are usually a meaningful number of unfilled positions—though they are still competitive.

Eligibility for SOAP

You must:

• Be eligible to enter residency (graduated or graduating from an accredited DO program).
• Have registered for the NRMP Match.
• Be partially matched (e.g., prelim but not categorical) or unmatched after the main Match algorithm.
• Not have withdrawn or been barred from the Match.

Your SOAP eligibility status appears in your NRMP account during Match Week.

Why SOAP Is Particularly Relevant for DO Graduates

As a DO graduate:

• You may be competing with both MD and DO applicants in a now single accreditation system.
• Some internal medicine residency programs may have a strong track record of accepting DO graduates, while others may not.
• If your initial osteopathic residency match or allopathic internal medicine attempts were unsuccessful, SOAP is a second structured chance.

Importantly, many IM programs appreciate DO graduates’ strong clinical training and OMT background, especially in community and academic-community settings. Your job during SOAP is to make that value immediately clear.

---

Pre–Match Week SOAP Preparation: What to Do Weeks in Advance

SOAP success is built before Match Week begins. Treat SOAP preparation like a parallel project while you’re waiting for Match results.

1. Clarify Your Internal Medicine Residency Targets

Before Match Week, take time to define your realistic targets:

• Preferred program types:
  • Community-based internal medicine residency
  • University-affiliated community programs
  • Academic IM programs
• Geographic flexibility:
  • Are you open to relocating anywhere in the U.S.?
  • Are there absolute no-go locations?

During SOAP, you often need to be more flexible than during the main IM match, especially with location and prestige. However, know your hard boundaries (e.g., family obligations or visa issues) so you’re not making rushed decisions you truly can’t live with.

2. Assess Your Application Honestly (as a DO Applicant)

Do a candid review of your application profile:

• COMLEX and/or USMLE scores (including any failures or late passes)
• Clinical grades and internal medicine clerkship performance
• Letters of recommendation—how strong and IM-specific they are
• Research, QI projects, leadership, and volunteer work
• Any red flags (gaps, professionalism issues, exam failures)

This will guide how you:

• Choose the right tier of programs to SOAP.
• Frame your narrative in emails and interviews.
• Decide how aggressively to broaden your SOAP strategy (e.g., medicine prelim vs categorical, community vs academic).

3. Update and Tailor Your ERAS Application for Internal Medicine

During SOAP you cannot radically overhaul your ERAS application, but small, targeted improvements ahead of time can help.

Key areas to refine:

• Personal Statement (Internal Medicine–Focused)

  • Write a clear, concise statement specifically tailored to internal medicine residency.
  • Highlight your DO perspective: whole-person care, communication skills, continuity of care, and OMT where relevant.
  • Emphasize clinical experiences, especially inpatient internal medicine rotations, sub-internships, and any acting internship.

• Experiences

  • Ensure IM-relevant experiences are listed clearly and described with action verbs and measurable impact.
  • Highlight:
    • Internal medicine sub-I or acting internship
    • Hospitalist shadowing or work
    • Quality improvement or patient safety projects
    • Longitudinal primary care or continuity clinics

• Program Signaling & Geographic Ties

  • If you’ve already signaled IM programs, that’s done before SOAP. But in your communication and interviews, be prepared to emphasize geographic familiarity, rotations in the region, or family ties.

4. Optimize Letters of Recommendation for IM Match and SOAP

For SOAP, having strong internal medicine letters is a major asset.

Aim for:

• At least two letters from internal medicine attendings.
• Ideally one from a sub-I or acting internship where you worked closely with an IM team.
• At least one letter that explicitly supports your readiness for categorical internal medicine residency.

If possible:

• Politely ask recommenders to update letters with the most recent clinical experiences (if something significant has changed).
• Ensure letters are uploaded to ERAS well before Match Week.

5. Build a SOAP Program Research System in Advance

You won’t know which programs have unfilled positions until Monday of Match Week, but you can:

• Create a spreadsheet with columns for:
  • Program name
  • Institution and location
  • ACGME accreditation ID
  • DO-friendliness (e.g., past DO graduates, COMLEX acceptance)
  • Program type (community, academic, hybrid)
  • Notes about curriculum/features
  • Contact emails (program director, coordinator)
• Pre-populate with internal medicine programs where:
  • You’d realistically be competitive.
  • You’d seriously consider training.
  • There is a history of accepting DO graduates or COMLEX scores.

During SOAP you’ll drop in which of these programs actually appear on the List of Unfilled Programs and update quickly.

6. Prepare a SOAP-Specific Communication Toolkit

Before Match Week:

• Draft email templates (more on structure later) for:
  • Initial outreach to programs during SOAP.
  • Thank-you/follow-up after short interviews.
• Prepare a 2–3 sentence “elevator pitch” summarizing:
  • Who you are (DO graduate, where from).
  • Your interest in internal medicine.
  • What you offer as a resident.
• Practice 30–60 second responses for:
  • “Tell me about yourself.”
  • “Why internal medicine?”
  • “Why our program?”
  • “Why were you not initially matched, and what have you done since?”

7. Logistics: Technology and Schedule

During SOAP, response times can be short. Prepare:

• Reliable internet and a quiet space for phone or video interviews.
• Headphones or earbuds, and a tested webcam.
• A professional background (neutral, tidy) and interview clothes ready.
• Clear your schedule for Match Week, especially Monday–Thursday.

---

Match Week: Step-by-Step SOAP Strategy for Internal Medicine

Match Week has a specific, strict timeline. Knowing it helps you plan each move.

Monday: Unmatched Notice and List of Unfilled Programs

Monday 11:00 AM ET (approximately):
You learn whether you’re:

• Fully matched
• Partially matched
• Unmatched

If you are SOAP-eligible and unmatched/partially matched:

• You gain access to the NRMP List of Unfilled Programs and can see specialties and program details.
• You may not contact programs yet; communication rules are very strict.

Action steps:

1. Filter the list for internal medicine residency:
   • Identify categorical and preliminary internal medicine positions.
   • Note which are:
     • Categorical IM positions (most desirable if you want full IM training).
     • Transitional/preliminary years (can be useful but require planning for PGY-2 onward).
2. Cross-reference with your spreadsheet:
   • Mark DO-friendly or COMLEX-accepting programs.
   • Prioritize programs where your profile is a realistic fit.

Monday–Tuesday: Applying Through ERAS

During the SOAP application window, you:

• Can apply to up to 45 programs total.
• Must submit applications only via ERAS (not directly by email).
• Should prioritize internal medicine programs that:
  • Are DO-friendly.
  • Match your academic profile (scores, experiences).
  • Fall within your geographic flexibility.

Strategy for choosing internal medicine programs:

• Tier 1 (high priority):
  • DO-friendly IM programs in regions you prefer, where your scores are close to or above their usual range.
• Tier 2 (moderate priority):
  • Programs where you might be slightly below average but still within a reasonable range.
• Tier 3 (safety/backup category):
  • Programs in less popular locations or smaller community hospitals but fully accredited and with solid training.

For each program, consider:

• Program’s track record with DOs (check their website, current residents).
• Size of the program (larger programs may be more flexible).
• Visa policies (if applicable).

Communicating with Programs: Rules and Best Practices

During SOAP:

• You may not contact programs about unfilled positions until they initiate contact or as permitted by current NRMP rules.
• Programs may reach out to you via:
  • ERAS message center
  • Email
  • Phone
• When contacted, respond promptly and professionally.

If rules permit some outreach (this can vary slightly by year; always check current NRMP/ERAS guidelines):

• Keep any communication brief, respectful, and non-pushy.
• Never pressure a program for an offer or commit to more than you intend to honor.

---

Crafting Your Message and Interview Performance as a DO IM Applicant

You’ll often have only minutes to make an impression—sometimes in a 10–15 minute phone call. Be prepared to clearly communicate your value as a DO graduate interested in internal medicine.

Core Talking Points for DO Graduates

1. Your DO Identity as a Strength

   • Emphasize:
     • Training in holistic care, communication, and empathy.
     • Osteopathic principles in chronic disease management, multimorbidity, and functional status.
   • Mention OMT when relevant, but don’t make it the only highlight—focus on being a strong general IM resident first.

2. Commitment to Internal Medicine

   • Be able to describe:
     • A defining IM clinical experience.
     • Why you prefer internal medicine over other specialties.
     • How you see your long-term career (hospitalist, primary care, subspecialty, academic medicine, etc.)

3. Clinical Readiness

   • Highlight:
     • Strong evaluations on internal medicine rotations and sub-I.
     • Comfort with inpatient workflow, call nights, cross-cover, and managing common IM conditions (CHF, COPD, diabetes, sepsis, etc.).
     • Any hands-on experience with procedures (paracentesis, thoracentesis, lumbar puncture—if applicable).

4. Addressing Not Matching in the Initial IM Match

If asked, respond briefly and confidently:

• Avoid blaming others or sounding bitter.
• Frame it around:
  • Competitiveness of the IM match.
  • Late improvements in your application (e.g., better CS/COMLEX Level 2/Step 2 performance).
  • Geography or program selectivity.
• Pivot quickly to:
  • What you have done to improve since applying:
    • Additional clinical rotations.
    • Additional letters of recommendation.
    • New QI or research work.
    • Focused board review or remediation.

Sample Short Answer Structures

“Tell me about yourself.”

“I’m a DO graduate from [School], originally from [Region]. I’ve been drawn to internal medicine since my third-year core rotation, where I really connected with managing complex, chronic conditions on the inpatient service. Over my sub-internship at [Hospital], I enjoyed working closely with the interdisciplinary team and taking primary responsibility for my patients. I see myself as a future hospitalist in a community setting, and I’m looking for a program where I can grow as a clinician, teacher, and team player.”

“Why internal medicine?”

“I enjoy thinking broadly about patients and integrating multiple comorbidities into one cohesive plan. Internal medicine allows me to build long-term relationships while also managing acute issues in the hospital. I especially like the diagnostic reasoning aspect—sorting through complex presentations to identify the underlying pathology and coordinate care. My DO training emphasizes whole-person care, which fits naturally with internal medicine’s focus on continuity, communication, and prevention.”

Email Template (If Outreach Is Permitted)

Always verify current NRMP rules before sending any emails. If allowed, here is a brief, professional template:

Subject: SOAP Applicant – Internal Medicine – [Your Name], DO

Dear Dr. [Last Name] / Program Coordinator,

My name is [Full Name], DO, a recent graduate of [Medical School]. I am a SOAP-eligible applicant in the 2025 Match with a strong interest in categorical internal medicine residency. I have applied to your program through ERAS and wanted to briefly express my enthusiasm for the opportunity to train at [Program Name].

During my internal medicine sub-internship at [Institution], I developed a strong foundation in inpatient care, managing common conditions such as CHF, COPD exacerbations, and sepsis under close supervision. I am particularly drawn to your program’s [mention specific feature: community focus, continuity clinic structure, emphasis on underserved populations, or research/QI opportunities].

I would be grateful for the opportunity to speak with you or a member of your team if you are reviewing SOAP applicants. Thank you for your time and consideration.

Sincerely,
[Your Full Name], DO
AAMC ID: [ID]
Phone: [Number]
Email: [Email]

---

Decision-Making During SOAP: Offers, Categorical vs Prelim, and Long-Term Strategy

SOAP offers come in up to four rounds, typically on Wednesday and Thursday of Match Week. In each round:

• You may get zero, one, or multiple offers.
• You may accept only one offer in a round.
• Once accepted, you are contractually committed and exit SOAP.

Categorical Internal Medicine vs Preliminary Positions

As a DO graduate targeting internal medicine, you should:

1. Prioritize categorical IM positions

   • These positions provide a full 3-year path to board eligibility in internal medicine.
   • They are generally better for long-term stability and training continuity.

2. Use preliminary IM only as part of a deliberate plan

   • Prelim IM or transitional year can make sense if:
     • You are aiming to re-enter the main IM match later.
     • You are considering other specialties requiring a prelim year.
   • But prelim alone does not guarantee you’ll find a PGY-2 spot.

If you receive:

• Categorical IM offer at a reasonable program/location → Usually wise to accept.
• Only prelim offers → Evaluate:
  • Strength and reputation of the prelim program.
  • Your realistic chance of securing a PGY-2 or reapplying successfully.
  • Your financial and personal situation (relocation, family, etc.).

Evaluating a SOAP Internal Medicine Offer

When you get an offer, you have a limited time window to respond. Quickly consider:

• Program accreditation and stability
  • Fully ACGME-accredited, not on probation.
• Training quality
  • Mix of inpatient/outpatient.
  • ICU experience.
  • Fellowship match patterns (if you’re fellowship-minded).
• Supportive environment
  • Evidence of DO graduates in current or past classes.
  • Reasonable work hours and wellness culture.
• Location practicality
  • Cost of living, support network, and feasibility of relocation.

Ask yourself:

• Does this program offer you solid internal medicine training and board eligibility?
• Can you see yourself living and working there for at least three years?
• Is this meaningfully better than attempting another full application cycle without a position?

For many SOAP applicants, a solid community internal medicine residency—even if not initially top choice—can lead to excellent careers as hospitalists, primary care physicians, or subspecialists.

---

Emotional Resilience and Next Steps If SOAP Doesn’t Work Out

Not matching in the main IM match is painful; going through SOAP adds another layer of stress. Your mental framework matters—for interviews, decision-making, and your longer-term path.

Managing Stress During SOAP

• Structure your day:
  • Dedicated blocks for application review.
  • Time-limited breaks for exercise or mindfulness.
• Designate a support person:
  • A trusted friend, partner, mentor, or advisor.
  • Someone who can help you stay grounded and objective.

If You Do Match Through SOAP

Once you accept a SOAP offer:

• Celebrate quietly—this is a major achievement under difficult circumstances.
• Quickly complete any required paperwork, onboarding forms, and credentialing requests from your new program.
• Shift focus to:
  • Internal medicine board prep resources.
  • Clinical readiness for intern year (especially if you had any gaps).

If You Don’t Match Through SOAP

If SOAP doesn’t result in a position:

1. Debrief with an advisor or mentor

   • Review:
     • Strengths and weaknesses of your application.
     • Types of programs you targeted.
     • Interview performance and communication.

2. Plan your next steps strategically

   • Consider:
     • A structured research year (particularly at an IM department).
     • A hospitalist scribe or clinical assistant role, if meaningful and supervised.
     • Additional auditions or observerships where allowed.

3. Rebuild your application for the next IM Match

   • Strengthen:
     • Clinical experience (especially recent).
     • Letters of recommendation.
     • Board scores (if retakes or additional exams are an option).
     • Narrative clarity—why internal medicine, why now, why you’re more prepared.

Even if the SOAP residency process doesn’t succeed, your long-term goals in internal medicine remain reachable with a clear, deliberate plan.

---

FAQs: SOAP Preparation for DO Graduates in Internal Medicine

1. As a DO graduate, do I have a realistic chance of getting an internal medicine residency through SOAP?
Yes. Internal medicine often has some unfilled positions after the main IM match, and many of these programs are DO-friendly. Your chances improve if you are geographically flexible, target programs aligned with your academic profile, have strong IM letters, and present yourself confidently as a DO-trained future internist.

2. Should I apply only to categorical internal medicine programs during SOAP, or include prelim positions too?
Prioritize categorical IM positions first—they provide a full path to board certification. If you still have unused applications and the categorical options are limited, consider prelim IM or transitional years as secondary options, but only as part of a clear plan for what you’ll do after that year.

3. Can I contact programs directly during SOAP to express interest?
SOAP communication rules are strict and time-specific. In general, you cannot initiate contact about unfilled positions before or outside NRMP rules. Programs may reach out to you first. The safest approach is to closely follow current NRMP/ERAS guidelines each year; if limited outreach is allowed, keep it brief, professional, and never pressure for offers.

4. What are the most important parts of my application to optimize for an internal medicine SOAP attempt?
For DO graduates targeting IM, the highest-yield pieces are:

• A clear, IM-focused personal statement.
• Strong internal medicine letters of recommendation.
• Evidence of solid clinical performance in IM rotations and sub-I.
• A coherent narrative explaining your commitment to internal medicine and any improvements you’ve made since your original applications.

With systematic SOAP preparation—documents ready, strategy set, communication practiced, and expectations realistic—you significantly increase your likelihood of securing an internal medicine residency position, even under the intense conditions of Match Week.