Essential SOAP Preparation Guide for Emergency Medicine-Internal Medicine Residency

Preparing effectively for the Supplemental Offer and Acceptance Program (SOAP) is crucial for any student aiming to train in an Emergency Medicine-Internal Medicine (EM IM) combined residency. The stakes are high, time is short, and competition for EM IM combined spots is intense. A strategic, calm, and well-organized SOAP preparation plan can be the difference between scrambling aimlessly and matching into a well-aligned training opportunity.

Below is a detailed, step-by-step guide tailored specifically to Emergency Medicine-Internal Medicine applicants.

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Understanding SOAP in the Context of EM-IM

Before doing any SOAP preparation, you must clearly understand what is SOAP, how it works, and how it uniquely affects Emergency Medicine-Internal Medicine candidates.

What is SOAP?

SOAP (Supplemental Offer and Acceptance Program) is the formal, structured process that allows unmatched or partially matched applicants to secure unfilled residency positions in the week of Match Week.

Key features:

• Eligibility-based: You must be SOAP-eligible (as determined by NRMP and ERAS) to participate.
• Time-limited: Runs only during Match Week with strict, short deadlines.
• Offer rounds: Programs and applicants go through several “rounds” where offers are extended and must be accepted or rejected within a tight time window (usually 2 hours per round).
• Centralized communication: All communication and offers go through ERAS/NRMP systems—no direct solicitation of programs by phone or email during SOAP.

How SOAP Intersects with EM IM Combined

Emergency Medicine-Internal Medicine combined programs are relatively small in number and often highly competitive. This has several implications:

1. Very few EM-IM combined unfilled spots: In many cycles, there may be:

   • Zero or only a handful of EM IM combined positions in SOAP.
   • If EM IM combined spots are available, they are often clustered at certain institutions.

2. Need for flexibility across related specialties:

   • You may need to consider:
     • Categorical Emergency Medicine positions
     • Categorical Internal Medicine positions
     • EM-focused preliminary or transitional year programs (less common, but sometimes a bridge)
   • Your SOAP strategy should anticipate multiple related pathways, not just EM-IM combined.

3. Unique applicant profile:

   • Many EM IM candidates have:
     • Broad clinical interests
     • Significant leadership, research, or global health exposure
     • Strong letters from both EM and IM
   • This breadth can be used as a clear asset when pivoting to EM-only, IM-only, or other related fields in SOAP.

In short, SOAP preparation for an EM-IM combined applicant means planning for:

• The ideal (an EM IM combined spot in SOAP), and
• Multiple realistic backup paths in EM, IM, or related areas.

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Step 1: Pre–Match Week Preparation (The Work You Must Do Early)

Successful SOAP residency outcomes are mostly determined before Match Week begins. Treat SOAP preparation like an insurance policy: you hope not to need it, but you must build it carefully.

1.1 Clarify Your Career Priorities

Start by answering these questions honestly:

1. If I do not match EM IM combined, what is my top alternative?

   • Categorical Emergency Medicine?
   • Categorical Internal Medicine with a plan to do EM shifts, hospitalist work, or a critical care fellowship?
   • A Preliminary Internal Medicine or Transitional Year position with a plan to reapply?

2. Is my life goal more “dual-trained at all costs” or “practicing in an acute care setting, even if through a single specialty”?

   • If dual-training is non-negotiable, you may accept a prelim position and reapply.
   • If practicing acute care is the priority, you might favor categorical EM or IM opportunities.

3. Geography vs. specialty:

   • Are you willing to move anywhere for Emergency Medicine-Internal Medicine, or is location a firm constraint?
   • In SOAP, flexibility on geographic location is often critical.

Write down your priority ranking before Match Week, when emotions are lower.

Example ranking:

1. EM IM combined position (anywhere)
2. Categorical EM
3. Categorical IM (prefer academic IM, then community IM)
4. Prelim IM / Transitional Year (in a region I can see myself long-term)

1.2 Update and Customize Your Application Materials

You must assume that, if you need SOAP, you’ll have very limited time to adapt documents. Prepare modular core documents now:

1. Core ERAS CV & Activities

   • Ensure:
     • All experiences are updated
     • Dates, locations, and responsibilities are accurate
     • EM- and IM-related experiences are clearly highlighted
   • Add detail for:
     • EM sub-internships
     • IM sub-internships
     • Research, quality improvement, and leadership

2. Multiple Personal Statements Ready Prepare at least three polished versions:

   • EM IM combined–focused statement
     • Emphasize dual passion: acute resuscitation (EM) + longitudinal management (IM)
     • Highlight experiences that bridge both worlds, e.g., ICU rotations, ED–ward transitions, complex comorbidity management.
   • Categorical EM statement
     • Focus on emergency department experiences, rapid decision-making, teamwork, and shift-based resilience.
   • Categorical IM statement
     • Stress longitudinal care, diagnostic reasoning, multidisciplinary inpatient and outpatient care, and systems-based practice.

   Keep each statement:

   • 650–850 words
   • Tight, specific, and with clear narrative arcs tailored to that specialty.

3. Letter of Recommendation Strategy

   • Identify which letters most strongly support:
     • Combined EM IM (ideally: 1–2 EM letters + 1–2 IM letters)
     • Pure EM (at least 2 strong EM SLOEs or letters)
     • Pure IM (at least 2 IM letters, including an academic IM letter if possible)
   • Confirm with your dean’s office or ERAS coordinator:
     • How quickly letters can be reassigned or re-targeted during SOAP.
   • Ask letter writers (if appropriate) whether they would support you in either EM, IM, or EM IM combined—this ensures the tone fits your SOAP plans.

4. MSPE / Dean’s Letter

   • This is largely fixed, but:
     • Ensure it is error-free.
     • Know where your strengths and weaknesses are highlighted so you can address them in interviews during SOAP.

1.3 Academic and Performance Risk Assessment

With your advisor or EM-IM mentor, identify risk factors that might lead to SOAP:

• USMLE/COMLEX scores below typical EM IM combined cutoffs
• Failures or repeats of Step exams or clerkships
• Late EM or IM rotations or late SLOEs
• Limited geographic flexibility
• Limited EM IM combined applications or interviews

For each risk factor, define a mitigation strategy you can articulate to program directors during SOAP interviews:

• What changed?
• What did you learn?
• How have you improved?

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Step 2: Building a SOAP Strategy for EM IM and Related Programs

Once your documents are ready, you need a clear strategic framework for SOAP residency applications specific to Emergency Medicine-Internal Medicine.

2.1 Understanding How Applications Work During SOAP

During SOAP:

• You’ll receive access to the List of Unfilled Programs on Monday of Match Week at a specific time.
• You can submit a limited number of applications (often up to 45 programs total) to unfilled positions through ERAS.
• You cannot contact programs proactively to solicit positions, but you can respond if they reach out to you.

Because the number of EM IM combined programs in SOAP is usually small, plan your 45 applications thoughtfully:

• EM IM combined positions (if available): Top priority
• Categorical EM (if aligned with your goals)
• Categorical IM programs (especially those with strong ED, ICU, or hospitalist tracks)

2.2 Tiering Your Target Programs

Create a tiered priority list before you see the unfilled list, based on:

1. Program Type

   • Tier 1: EM IM combined programs
   • Tier 2: Categorical EM programs
   • Tier 3: Academic IM programs with strong critical care or ED exposure
   • Tier 4: Community IM programs with strong inpatient and procedural opportunities
   • Tier 5: Prelim IM or transitional year programs (if planning to reapply)

2. Personal Considerations

   • Geography (family, partner, visa status)
   • Program reputation and prior track record with EM, EM-IM, or critical care
   • Fit with your long-term career goals (dual boarding vs strong hospitalist vs ED practice)

When the unfilled list appears, you will:

• Quickly cross-reference it with your tiers.
• Adapt your final application list to stay within allowed limits.

2.3 Using Your EM-IM Background as an Asset

Even when applying for categorical EM or IM positions during SOAP, your EM-IM aspirations can be reframed as a strength rather than a liability.

For EM programs:

• Emphasize:
  • Depth of your internal medicine exposure.
  • Comfort with complex comorbidities and chronic disease.
  • Your ability to interface with inpatient teams, ICU, and consultants.
• Message: “I will be an ED physician who comprehensively understands the inpatient and chronic care ramifications of ED decisions.”

For IM programs:

• Emphasize:
  • Strong skills in rapid assessment, initial resuscitation, and acute decision-making.
  • ED and urgent care experiences that enrich your differential diagnosis and triage judgment.
• Message: “I will be an internist who is exceptionally comfortable managing acute decompensation and transitions from ED to floors/ICU.”

This dual lens can differentiate you positively from applicants focused on only one setting.

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Step 3: Execution During Match Week – A Detailed SOAP Timeline

Match Week moves fast. Having a timeline template reduces stress and errors.

3.1 Monday Morning: Results and Emotional Stabilization

When you receive your result (unmatched or partially matched):

1. Allow a brief emotional reaction (30–60 minutes).

2. Quickly transition to structured action:

   • Contact your dean’s office, EM-IM advisor, and specialty mentors.
   • Let them know you’re SOAP-eligible and seeking:
     • EM IM combined if available
     • EM or IM positions as per your plan

3. Clarify your status:

   • Fully unmatched?
   • Partially matched (e.g., matched to an advanced position but not prelim, or vice versa)?
   • Your strategy changes depending on which slots you still need.

3.2 Monday: Analyzing the Unfilled List

Once NRMP releases the unfilled list:

1. Identify EM IM combined positions:

   • Immediate priority if any are present.
   • Look up:
     • Program websites
     • Any prior communication you’ve had with them
   • Decide which personal statement to attach (likely EM-IM specific).

2. Identify suitable EM and IM programs:

   • Use your tier system.
   • Filter by:
     • Visa policies
     • Geographic flexibility
     • Program size and type

3. Consult in real-time:

   • Share a draft application target list with your advisor.
   • Refine which programs receive:
     • EM-focused personal statement
     • IM-focused personal statement
     • EM-IM combined statement (for dual programs)

3.3 Monday–Tuesday: Submitting SOAP Applications

Follow these principles:

• Use all or nearly all of your allotted applications unless clearly not beneficial.
• Avoid scattershot applications to unaligned specialties just to “get in somewhere,” unless you are truly prepared to train in that area.
• Apply thoughtfully to:
  • All EM IM combined programs on the list.
  • EM programs where your profile is reasonably competitive.
  • IM programs that can still position you for an acute-care career (hospitalist, ICU, EM re-application).

Double-check for each program:

• Correct personal statement selected.
• Correct letters attached (EM-heavy for EM, IM-heavy for IM, balanced for EM-IM).

3.4 Tuesday–Thursday: Program Contact and Interviews

Programs that are interested may reach out for:

• Phone calls
• Video interviews
• Rapid screening conversations

Be prepared with:

1. A 60-second “SOAP pitch” tailored by program type

For EM-IM combined:

“I’m deeply committed to a dual career caring for acutely ill patients in both ED and inpatient settings. My rotations in the ED and on medicine wards showed me how critical it is to bridge those systems. My long-term goal is to practice in a setting where I can contribute to both emergency care and complex chronic disease management, including ICU-level care, and engage in teaching and systems improvement across the continuum.”

For EM:

“I am passionate about emergency medicine because it combines rapid decision-making, team-based care, and immediate impact on patients in crisis. My strong internal medicine background gives me confidence managing complex comorbidities and anticipating downstream consequences of ED decisions. I see myself as an EM physician who collaborates closely with inpatient teams to optimize care transitions and outcomes.”

For IM:

“I am committed to internal medicine because I value longitudinal patient relationships, diagnostic complexity, and multidisciplinary care. My emergency medicine experiences sharpened my skills in rapid stabilization and initial management, which I bring to the care of decompensating inpatients and to triage decisions. I hope to be an internist who is particularly strong in acute care settings like the wards and ICU, and to help bridge the ED–inpatient interface.”

2. Prepared answers to predictable questions:
   • Why do you think you went unmatched?
   • Why are you interested in our program specifically?
   • If we offer you a categorical IM spot, how do you see your career evolving?
   • Would you be committed to our program if offered a position through SOAP?

Be honest but forward-looking:

• Address any academic issues.
• Focus on growth, reflection, and concrete changes in studying or clinical performance.

3.5 Offer Rounds: Making Fast, Informed Decisions

During SOAP, each offer round has a short acceptance window. Preparation prevents panic-driven decisions.

Before the first offer round:

• Decide in advance:
  • Which types of offers you will always accept (e.g., EM IM combined).
  • Which require a quick conversation with a mentor but are likely yes (e.g., strong categorical EM program).
  • Which you would decline because they are misaligned with your goals.

Once an offer arrives:

• You usually cannot hold offers while waiting for a “better one” in that round.
• Accepting a SOAP position typically removes you from further SOAP participation for that category of position.
• Align your decision with the priorities you wrote pre–Match Week, not with fear in the moment.

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Step 4: Special Considerations for EM-IM Applicants in SOAP

Emergency Medicine-Internal Medicine combined applicants face unique choices and risks in SOAP. Address these explicitly.

4.1 Balancing the Dream vs. the Secure Path

You may face a decision between:

• A less-than-ideal EM IM combined spot (e.g., non-preferred geography), and
• A strong categorical EM or IM position in a preferred location or institution.

Questions to ask yourself:

• Is dual boarding a core identity goal, or a strong preference?
• Are you willing to relocate anywhere for 5 years of EM IM combined training?
• Would a solid categorical EM or IM program still allow you to build a career close to what you envisioned (e.g., ICU focus, ED–hospitalist hybrid roles)?

Discuss these scenarios with:

• EM-IM trained physicians
• EM-only and IM-only mentors
  They can provide realistic views of career flexibility.

4.2 Planning for a Reapplication Year

If SOAP results in a preliminary or transitional year rather than a categorical spot, you may plan to reapply to EM-IM combined, EM, or IM.

Key steps:

• Choose a prelim or TY program with:
  • Strong IM or ED exposure
  • Opportunities for research, QI, and mentorship
  • Supportive leadership for reapplication
• Use that year to:
  • Strengthen clinical evaluations
  • Generate new letters
  • Address any prior gaps (test scores, professionalism, limited clinical experiences)

Be ready to explain in future interviews:

• Why you didn’t match initially
• What you accomplished during the interim year
• Why you remain committed to EM-IM, EM, or IM

4.3 Visa and International Medical Graduate (IMG) Issues

For IMGs or applicants needing visas, SOAP is more complex:

• Examine which unfilled programs:
  • Sponsor J-1 and/or H-1B.
  • Have a track record of training IMGs.
• Prioritize:
  • Programs explicitly open to IMG/visa candidates.
  • Academic centers or large community hospitals more accustomed to complex visa processes.

Communicate clearly during interviews:

• Your visa status.
• Any prior US clinical experience in EM, IM, or both.
• Your long-term plans if training in the US.

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Step 5: After SOAP – Debriefing and Next Steps

Regardless of the SOAP outcome, the week will be emotionally and mentally exhausting. A deliberate post-SOAP process will help you start residency stronger.

5.1 If You Match Through SOAP

• Celebrate, rest briefly, then:
  • Reach out to your new program to express gratitude and enthusiasm.
  • Clarify next steps (onboarding, paperwork, housing, etc.).
  • Begin reading and preparation tailored to the specific specialty you matched into (EM, IM, or EM-IM combined).

For EM-IM combined:

• Ask about:
  • Program structure (block vs longitudinal).
  • Early ED vs ward/ICU exposure.
  • Mentorship options from faculty dual-trained in EM and IM.

For categorical EM or IM:

• Consider how to:
  • Maintain your interests in both domains (e.g., ICU rotations, ED electives, quality improvement projects bridging ED–inpatient care).
  • Shape a career that captures some of what attracted you to EM IM combined training.

5.2 If You Do Not Secure a Position Through SOAP

This is a painful outcome—but not the end of your path.

Steps:

1. Take time for emotional processing and support.
2. Schedule detailed debriefs with:
   • Your dean’s office
   • EM-IM, EM, and/or IM faculty mentors
3. Develop a 1–2 year recovery and reapplication plan:
   • Options may include:
     • Research fellowship (ED-based or IM-based)
     • Non-ACGME clinical roles (e.g., ED scribe, research coordinator, clinical assistant roles where allowed)
     • Additional observerships or US clinical experience (especially for IMGs)
   • Create a timeline for:
     • Retaking exams if needed
     • Publishing or presenting research
     • Strengthening letters and clinical evaluations

Keep written notes on:

• What worked and what didn’t in your SOAP preparation.
• Any feedback you received from programs.
• How you’ll concretely improve for the next application cycle.

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FAQs: SOAP Preparation for EM-IM Applicants

1. How likely is it to find an EM IM combined position in SOAP?
Historically, very few EM IM combined positions go unfilled and appear in SOAP; in some years, there may be none. Because the total number of EM-IM combined programs and positions is small, most fill in the main Match. You should be fully prepared that your SOAP options may consist primarily of categorical EM or IM positions, not EM IM combined spots.

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2. Should I apply to both EM and IM in SOAP, or focus on just one?
For many EM-IM applicants, it is reasonable to apply to both EM and IM programs during SOAP, depending on:

• Your career priorities.
• Strength of your EM vs IM letters and experiences.
• The composition of the unfilled list.

If your application is substantially stronger in one specialty (e.g., more SLOEs and EM rotations), it can be wise to focus more heavily there. However, keeping both options on the table can maximize your chances of securing a position aligned with your long-term goals.

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3. Will programs in SOAP see that I originally applied to EM-IM combined programs?
Programs can generally see your ERAS application history, including your personal statement and experiences, and may infer your original focus. This is not inherently negative. You should be ready to explain your initial interest in EM IM combined and how it naturally aligns with your interest in their single-specialty program:

• For EM: emphasize acute care and your IM strength improving ED care.
• For IM: emphasize complex acute management skills from ED experiences and interest in inpatient/ICU work.

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4. How can I talk about not matching without hurting my chances in SOAP?
Focus on a balanced, forward-looking explanation:

• Briefly acknowledge key factors (e.g., late EM SLOEs, lower board scores, limited geographic flexibility).
• Emphasize what you’ve learned and how you’ve grown.
• Highlight concrete steps you’ve taken (improved study strategies, stronger clinical evaluations, additional mentorship).

Avoid blaming programs, institutions, or individuals. Frame your unmatched status as a temporary setback that has clarified your motivations and strengthened your commitment to training.

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Thoughtful, early SOAP preparation—tailored to the unique realities of Emergency Medicine-Internal Medicine combined training—positions you to respond quickly and strategically during one of the most high-stress weeks in medical training. By understanding the process, aligning your priorities, and using your dual-interest background as a strength, you can maximize your chances of securing a residency position that moves you toward the career you envision.