Ultimate Guide for DO Graduates: Preparing for SOAP in Cardiothoracic Surgery

Understanding SOAP as a DO Graduate Targeting Cardiothoracic Surgery

For a DO graduate with ambitions in cardiothoracic surgery, the Supplemental Offer and Acceptance Program (SOAP) can feel like the last safety net in a long and exhausting match season. Learning what SOAP is, how it works, and how to tailor your SOAP preparation to a highly competitive field like cardiothoracic surgery is essential—especially if you originally aimed for integrated cardiothoracic surgery (I-6) or categorical general surgery as a pathway to heart surgery training.

What Is SOAP?

The Supplemental Offer and Acceptance Program (SOAP) is a structured process run by the NRMP during Match Week that helps unmatched or partially matched applicants obtain unfilled residency positions in participating programs.

Key features:

• Occurs during Match Week, after you learn you are unmatched or partially matched
• Uses ERAS to apply to unfilled positions released by NRMP
• Structured into distinct rounds of offers, with periods to review, interview, and accept
• You can submit up to 45 new applications to unfilled programs

When thinking about what is SOAP as a DO graduate interested in cardiothoracic surgery, it’s less about directly matching into a cardiothoracic surgery residency (I-6 positions almost never appear in SOAP) and more about:

• Securing a strong surgical pathway (often general surgery)
• Maintaining geographic and professional flexibility
• Preserving your long-term trajectory toward heart surgery training

Why SOAP Matters Especially for DO Graduates

As a DO graduate, you face several realities:

• ACGME programs have become fully unified, but perceived bias toward MDs can persist in certain competitive specialties and academic centers.
• Cardiothoracic surgery residency is among the most competitive, with limited I-6 positions and heavy emphasis on board scores, research, and letters.
• Many DO applicants interested in cardiothoracic surgery use general surgery residency as the initial training platform.

For a DO graduate residency applicant aspiring to cardiothoracic surgery, SOAP is a strategic backup mechanism that can still keep you on track:

• You can SOAP into a preliminary or categorical general surgery spot that maintains your competitiveness for future cardiothoracic fellowships.
• You can pursue a year in a surgical preliminary program, transitional year, or strong internal medicine program to build your CV, get research, and reapply more competitively.

The goal is not “any spot at any cost,” but the best realistic position that keeps your heart surgery training dreams viable.

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Timeline and Mindset: Preparing for SOAP Before You Need It

SOAP is intensely time-compressed. Effective SOAP preparation must begin months before Match Week—long before you know your result.

Key Milestones and Timeline

4–6 months before Match Week (fall/winter):

• Clarify your primary target (e.g., I-6 cardiothoracic surgery, categorical general surgery).
• Define your back-up tiers, including SOAP-appropriate options:
  • Tier 1: Categorical general surgery
  • Tier 2: Preliminary surgery, surgical transitional year
  • Tier 3: Transitional year or strong internal medicine program at an academic center with cardiology/cardiothoracic research
• Discuss with your advisor how cardiothoracic fellowships regard these pathways.

2–3 months before Match Week:

• Update your CV and ERAS information so a SOAP version is almost ready:
  • New research abstracts, case reports, QI projects
  • Leadership and teaching updates
• Identify mentors in surgery and cardiothoracic surgery willing to:
  • Provide rapid advice during SOAP week
  • Make advocacy calls or emails if needed

1 month before Rank Order List deadline:

• Complete a “disaster plan” document:
  • Your priorities if unmatched (location vs. specialty vs. program caliber)
  • List of target SOAP specialties and program types
  • Draft personal statements for back-up specialties (surgery prelim, transitional year, internal medicine, etc.)

The week before Match Week:

• Review NRMP SOAP rules and official timeline.
• Ensure you can access:
  • ERAS and NRMP accounts
  • A quiet, private space and stable internet
  • Scanned documents if needed (updated CV, publications)
• Block time in your schedule for SOAP activities (no clinic/exams if possible).

This preparation allows you to act decisively and clearly if you learn on Monday of Match Week that you didn’t match.

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Strategic Positioning: Choosing Pathways That Preserve a Cardiothoracic Future

Because SOAP residency rarely offers integrated cardiothoracic spots, you need to understand and prioritize residency pathways that can still lead to a career in heart surgery.

1. Categorical General Surgery (Gold Standard Pathway)

• Best SOAP outcome for an unmatched DO interested in cardiothoracic surgery.
• Provides full 5-year training culminating in board-eligibility in general surgery.
• Well-recognized route to traditional cardiothoracic surgery fellowships.

What to look for in categorical programs during SOAP:

• Presence of cardiothoracic surgery faculty/fellowships
• Case volume in cardiac and thoracic surgery
• Opportunities for research in cardiothoracic or cardiac critical care
• DO-friendliness: prior DO residents, leadership openness to osteopathic graduates

2. Preliminary General Surgery Positions

Preliminary positions (1-year, non-categorical) are common in SOAP and can be a high-yield choice for future cardiothoracic applicants if approached strategically.

Advantages:

• Direct exposure to operative care, surgical culture, and perioperative medicine
• Opportunity to earn strong letters from surgeons and possibly cardiothoracic attendings
• Potential conversion to categorical spots at the same or another institution if you perform well

Risks and considerations:

• No guaranteed continuation beyond year one
• You must actively network and reapply during that year
• Quality of operative and educational experience can vary widely

For a DO graduate, a high-quality prelim surgery year (especially at an academic center with cardiothoracic surgery) can be more valuable for long-term heart surgery training than a random categorical program in a very distant specialty.

3. Transitional Year and Internal Medicine

If categorical or preliminary surgery is unavailable or not realistic, transitional year or strong internal medicine programs can still support a trajectory toward advanced training.

Transitional year programs:

• Provide broad clinical exposure, often with time for electives
• Can allow rotations in cardiothoracic surgery, cardiology, or ICU
• Good for research and networking, especially at academic centers

Internal medicine:

• Useful if you anticipate potential pivot to cardiology, critical care, or cardiac anesthesia if surgery opportunities remain limited
• At academic centers, can facilitate research in cardiac or thoracic disease, which may still support later surgical or interventional careers

4. Matching Strategy During SOAP

Before SOAP begins, define a priority matrix:

• Priority 1: Programs that offer a true surgical foundation and cardiothoracic exposure
• Priority 2: Programs that build academic/research capital in cardiovascular domains
• Priority 3: Programs that at least keep you clinically active and competitive for reapplication

Example prioritized SOAP list (for a DO cardiothoracic aspirant):

1. Categorical general surgery programs at mid-tier academic centers, especially DO-friendly
2. Preliminary general surgery programs at university or large community hospitals with cardiothoracic surgery service
3. Transitional year programs linked to hospitals with strong cardiac or pulmonary/critical care presence
4. Strong internal medicine programs with cardiology and CT surgery research opportunities

The key is to preserve your long-term cardiothoracic trajectory, not simply to fill a gap for one PGY-1 year.

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Step-by-Step SOAP Preparation for the DO Cardiothoracic Applicant

1. Data-Driven Self-Assessment

Before SOAP, realistically assess:

• USMLE/COMLEX scores (or absence of USMLE)
• Class rank, AOA/Sigma Sigma Phi status
• Surgery clerkship performance and sub-I evaluations
• Research output, particularly in surgery or cardiovascular topics
• Strength and seniority of your letters (CT surgeons, chairs, PDs, etc.)

This helps define your SOAP ceiling and floor—what is aggressively realistic and what is a safety net.

2. Refine Your Narrative for SOAP

Your SOAP personal statements and interviews must clearly communicate:

• Why you are committed to surgery (or your SOAP specialty)
• Why you want a surgical or cardiothoracic-related path despite being unmatched
• Why you, as a DO graduate, are prepared for a demanding, high-acuity environment

For a DO targeting cardiothoracic pathways, consider maintaining two versions of your PS:

1. General Surgery PS (SOAP version)

   • Emphasize operative interest, critical care, and long-term cardiothoracic ambitions.
   • Acknowledge being unmatched briefly and professionally, if asked; focus on how you improved your application since initial submission (e.g., research, new letters, rotations).

2. Transitional Year/Internal Medicine PS (SOAP version)

   • Emphasize cardiovascular interest, complex patient care, and flexibility for future specialization.
   • Highlight your interest in working with high-acuity cardiac or thoracic patients, even if through medicine or critical care.

3. Preparing Documents and ERAS for SOAP

SOAP is fast. Have the following pre-built or easily editable:

• Updated CV with:
  • Any late-breaking abstracts, publications, presentations
  • Leadership or quality improvement involving cardiac or surgical patients
• ERAS Application:
  • Correct and polished experiences section
  • Clearly identified surgery and cardiothoracic experiences
  • Refined “most meaningful experiences” that align with a surgical and CT-focused narrative
• Multiple Personal Statements:
  • One for surgery
  • One for transitional year
  • One for internal medicine (if considering)
• Letters of Recommendation:
  • At least one strong surgeon letter
  • Ideally one from a cardiothoracic surgeon if available
  • A strong core clinical letter (e.g., IM or ICU) that speaks to your work ethic and bedside skills

4. Communication and Advocacy Plan

Identify who will advocate for you during SOAP:

• Surgery clerkship director
• General surgery or cardiothoracic surgery mentors
• Your dean’s office / career advisor
• Any program directors you’ve worked closely with

Plan how and when to contact them if you are unmatched:

• Ask them in advance: “If I end up in SOAP, may I contact you for quick advice or a possible advocacy email to programs?”
• During SOAP, they can:
  • Clarify fit with specific programs
  • Send a brief advocacy email or call a PD they know
  • Help you avoid low-quality positions that might hinder your long-term goals

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Executing During SOAP Week: Tactics, Applications, and Interviews

Monday: Learning You Are Unmatched

You’ll receive notification from NRMP about your status:

• Unmatched or Partially Matched (e.g., PGY-1 only in an advanced program).

Emotional reaction is normal, but you must quickly shift into execution mode.

Immediate steps:

1. Meet (virtually or in person) with your dean’s office or advisor.
2. Review your pre-planned SOAP priority matrix.
3. Log in to ERAS/NRMP when the List of Unfilled Programs becomes available.

Identifying Target Programs

When the unfilled list goes live:

1. Filter by specialty:

   • General Surgery (categorical and preliminary)
   • Transitional Year
   • Internal Medicine

2. Further filter by:

   • Presence of cardiothoracic surgery service or fellowship
   • DO-accepting history (use program websites, FREIDA, or quick Google search)
   • Geographic or personal considerations (but be flexible—SOAP requires openness)

3. Create your ranking of application targets (up to 45):

   Example framework:

   • First 15–20: Categorical general surgery programs
   • Next 10–15: High-quality prelim surgery programs at academic or high-volume centers
   • Remaining: Transitional year and IM programs with strong cardiovascular connections

Customizing Applications

Even in time pressure, avoid sending one generic personal statement to all specialties.

• For general surgery programs:

  • Use your surgery-focused PS.
  • Highlight operative readiness, durability, and cardiothoracic interest.
  • If applying to prelim spots, acknowledge understanding of the prelim nature and your commitment to excel in that role.

• For transitional year/IM programs:

  • Use alternate PS versions.
  • Emphasize versatility, communication, and interest in complex cardiopulmonary disease.

Always tailor the “Personal Comments” or any free-text section in ERAS, if available, to your sincere interest in that specific program type.

SOAP Interviews: Presenting Yourself as a DO Future Cardiothoracic Surgeon

SOAP interviews are often short, focused, and virtual. You must convey quickly:

• Professionalism and composure despite not matching
• Genuine interest in their program (not just “any spot”)
• Clarity about how their program fits your cardiothoracic aspirations

Common SOAP interview questions and strong angles:

1. “Why do you think you didn’t match?”

   • Brief, honest, and non-defensive:
     • “I applied relatively narrowly to highly competitive programs in general surgery with a cardiothoracic focus. In retrospect, I should have broadened earlier. I’ve worked to strengthen my [research/letters/clinical skills] and I’m fully committed to proving myself if given the opportunity.”

2. “What are your long-term goals?”

   • Connect directly to cardiothoracic surgery residency or allied fields:
     • “My long-term goal is to become a cardiothoracic surgeon focusing on advanced heart failure surgery. I see your program’s strong ICU and thoracic experience as an ideal foundation for that path.”

3. “If you’re so focused on cardiothoracic, will you be satisfied here?”

   • Emphasize that great surgeons = great foundational training:
     • “I recognize that excellence in cardiothoracic surgery starts with excellence in general surgery and critical care. I’m committed to contributing fully to your service, and I believe that if I do my job well, the subspecialty opportunities will follow.”

As a DO graduate, you can also address osteopathic training positively if it comes up:

“My osteopathic background has given me a strong foundation in whole-person care and musculoskeletal understanding, which has been valuable on surgical services—especially in the ICU and post-op recovery. I’m excited to bring that skillset into an ACGME environment.”

Handling Offers and Rounds

SOAP has multiple offer rounds. Key guidance:

• Do not hold out unrealistically for a categorical surgery spot if your advisors strongly feel it is unlikely. Weigh each offer seriously.
• If you receive:
  • A categorical surgery offer at a solid program: almost always accept.
  • A prelim surgery offer at a strong academic center with CT surgery: often a very good bet if categorical offers seem unlikely.
  • A transitional year/IM offer at a top academic hospital: may still be a strategic choice if lower-quality surgery prelims are the only alternative.

Once you accept a SOAP offer, the process ends for you. Ensure that you:

• Understand the program’s expectations
• Confirm details with your dean’s office
• Start planning how to optimize that PGY-1 year for your long-term goals

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After SOAP: Maximizing Your Position for a Cardiothoracic Future

Regardless of whether you match via SOAP into categorical surgery, prelim surgery, or another field, you can still strategically pursue heart surgery training.

If You Matched into Categorical General Surgery

• Seek early exposure to cardiothoracic rotations.
• Get involved in CT surgery research and QI projects.
• Identify CT surgeon mentors by the end of PGY-1.
• Attend regional and national meetings (STS, AATS) if possible.

If You Matched into a Preliminary Surgery Program

• Treat this year as a 12-month audition:
  • Be the most reliable, prepared, and teachable intern on service.
  • Express interest in any internal categorical conversions that become available.
• Simultaneously:
  • Network with CT and general surgeons for letters.
  • Meet with your PD early to discuss realistic paths to categorical spots (at home or elsewhere).
  • Prepare to re-enter the Match (or off-cycle opportunities) with a greatly strengthened CV.

If You Matched into Transitional Year or Internal Medicine

• Request rotations in:
  • Cardiothoracic surgery, if allowed
  • Cardiology
  • ICU or cardiothoracic ICU
• Engage in cardiac or thoracic research to build a compelling narrative.
• Decide with mentors whether your plausible path is:
  • Re-applying to general surgery or integrated cardiothoracic
  • Pivoting to cardiology, critical care, or anesthesiology with a strong cardiac focus

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FAQs: SOAP and Cardiothoracic Surgery for DO Graduates

1. Can I realistically match into an integrated cardiothoracic surgery residency through SOAP?

Almost never. Integrated cardiothoracic surgery (I-6) spots are extremely limited and tend to fill in the main Match. It is exceptionally rare for an I-6 position to appear in SOAP. Your SOAP strategy as a DO should instead focus on general surgery pathways (categorical or prelim) or strong transitional/internal medicine options that preserve a future cardiothoracic trajectory.

2. As a DO graduate, will programs look down on me in SOAP compared to MDs?

Some competitive academic programs may still show subtle preference for MDs, but SOAP levels the playing field somewhat because programs urgently need to fill positions. Many general surgery and prelim programs are DO-friendly and have a track record of training osteopathic residents who go on to fellowships, including cardiothoracic. Your performance, professionalism, letters, and interview presence typically matter more than your degree alone.

3. How should I balance applying to categorical vs. preliminary surgery positions in SOAP?

If your advisors feel you are still competitive for categorical surgery, you should prioritize those programs first. However, in SOAP, categorical spots in surgery are limited. Many DO cardiothoracic aspirants will need to apply to a combination of:

• Categorical general surgery at realistic programs, and
• Preliminary general surgery at strong academic or high-volume centers, which can be excellent launching pads.

Use any remaining applications for transitional year or IM at institutions with strong cardiac or surgical presence as a back-up.

4. If I end up in a transitional year or internal medicine via SOAP, is my dream of heart surgery training over?

Not necessarily. Your path becomes less direct, but not impossible. Many cardiothoracic surgeons started in general surgery; fewer came from non-surgical pathways, but you can still:

• Use that year to build research credentials in cardiac or thoracic fields
• Reapply to general surgery with a stronger application
• Or pivot strategically to cardiology, critical care, or cardiac anesthesia, where you can still work closely with heart surgery teams.

Your long-term success will depend more on performance, mentorship, and perseverance than on a single SOAP outcome.

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By approaching SOAP preparation thoughtfully—as a DO graduate with a cardiothoracic surgery vision—you can transform a stressful, uncertain week into a strategically managed opportunity. The goal is not just to secure any SOAP residency spot, but to land in a position that keeps your trajectory toward heart surgery training very much alive.