Essential SOAP Preparation Guide for IMGs in Emergency Medicine-Internal Medicine

Understanding SOAP for IMGs Targeting EM–IM Combined Programs

For an international medical graduate (IMG) who is passionate about the Emergency Medicine–Internal Medicine (EM IM combined) pathway, the Supplemental Offer and Acceptance Program (SOAP) can feel both like a second chance and a high-pressure sprint. To use it effectively, you need to understand exactly what SOAP is, how it works, and how it specifically applies to the competitive and niche world of EM–IM combined training.

What Is SOAP?

SOAP (Supplemental Offer and Acceptance Program) is the structured process NRMP uses to fill unfilled residency positions after the main Match algorithm runs. It allows unmatched or partially matched applicants to apply to and accept positions in an organized and time-limited way rather than chaotic last‑minute scrambling.

In practical terms, SOAP residency is:

• A four-day process during Match Week.
• Limited to applicants who:
  • Registered for the NRMP Main Match,
  • Are eligible to start residency on July 1 (e.g., ECFMG certified by then for IMGs),
  • Are fully or partially unmatched after the algorithm runs.
• Conducted entirely through ERAS (applications) and NRMP R3 (offers/acceptances).

For IMGs, the IMG residency guide “rule of thumb” is: if you might not match, you must plan for SOAP weeks in advance. Last‑minute learning during Match Week is risky and stressful.

How Does SOAP Work?

Key structural points:

• Before Match Week

  • You submit ERAS applications as usual.
  • You do not apply for SOAP separately; eligibility is determined by NRMP.

• Monday of Match Week

  • 10:00 AM ET: You learn whether you are Matched, Partially Matched, or Unmatched.
  • If unmatched/partially matched & SOAP-eligible, ERAS opens access to the list of unfilled programs and the SOAP application functionality.

• SOAP Application Rules

  • Up to 45 ERAS applications total across all SOAP rounds.
  • Programs cannot see your previous application list; they only see the SOAP application you send them.
  • No direct unsolicited contacting of programs by applicants (or anyone representing you) outside allowed communication channels.

• Offer Rounds

  • Several rounds (typically 4) of offers over Wednesday–Thursday.
  • You can receive multiple offers in a round but can only accept one.
  • Once you accept an offer, you are bound to that program and exit SOAP.

EM–IM Combined Programs and SOAP: What to Expect

EM–IM combined (emergency medicine internal medicine) programs are:

• Small in number,
• Highly structured,
• Often extremely competitive,
• Rarely left with unfilled positions.

That means:

• You cannot rely on EM–IM combined spots appearing in SOAP.
• If any EM–IM positions do appear, they may go very quickly, often to U.S. grads or candidates with very strong prior relationships to the program.

However, for an IMG targeting EM–IM, SOAP still offers strategic opportunities:

1. Transition Pathways

   • Taking a categorical Internal Medicine or categorical Emergency Medicine spot in SOAP can keep you aligned with your long-term goal.
   • You may later pursue:
     • Transfer opportunities,
     • EM or IM fellowship options,
     • Critical care, hospitalist, or emergency care pathways that mirror combined training goals.

2. Bridge Strategies

   • Categoricals in IM (especially at institutions with EM–IM combined tracks) may allow:
     • EM elective time,
     • Strong combined mentorship,
     • Future EM fellowship or hybrid academic roles.

3. Resilience and Career Flexibility

   • Having a solid plan for “Plan B that still fits my EM–IM interests” is essential.

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Pre‑Match SOAP Preparation: Building a Strategic Backup Plan

SOAP preparation must begin months before Match Week, not after you learn you are unmatched. The key is to develop realistic, specialty-specific backup plans aligned with your EM–IM combined interests.

Step 1: Clarify Your Career Priorities

Ask yourself:

• Is my top identity EM, IM, or the combined practice?
• Which is more important:
  • Working in a fast-paced acute care setting (EM),
  • Building long-term patient relationships and complex multisystem management (IM),
  • Or having a hybrid career that combines both?

For an IMG targeting EM–IM combined, an effective SOAP strategy usually accepts that:

• A categorical EM or IM position is better than an unrelated specialty if EM–IM is your true goal.
• Geographic preferences will likely need to be flexible.

Write down:

1. Primary goal: EM–IM combined training.
2. Acceptable SOAP outcomes (e.g., categorical IM at academic center with strong EM, categorical EM in community program, prelim IM/transition year at academic site).
3. Non‑negotiables (e.g., visa sponsorship type, start date, board pass requirement).

Step 2: Understand Your IMG Profile Honestly

For IMGs, competitiveness in EM–IM combined (and EM generally) is affected strongly by:

• USMLE/COMLEX scores (especially Step 2 CK),
• Number of U.S. clinical rotations/USCE,
• Strength of letters from U.S. academic EM and IM faculty,
• Prior research, publications, or academic productivity,
• Communication skills and interview performance,
• Visa requirements (J‑1 vs H‑1B vs no visa needed).

If you suspect before Rank Order List (ROL) certification that your application is borderline for EM–IM combined or EM, assume you may need SOAP and prepare accordingly.

Step 3: Map Specialty Tiers for SOAP

Create a tiered plan using the lens of your EM–IM aspirations:

Tier 1: Ideal (if available in SOAP)

• Any EM–IM combined openings (rare, but monitor).
• Categorical Emergency Medicine at teaching hospitals that:
  • Have strong inpatient medicine,
  • Run observation units, ED‑ICU models, or internal medicine-heavy EDs.

Tier 2: Strong Alternatives

• Categorical Internal Medicine in academic or large community programs that:
  • Have robust ED relationships,
  • Offer EM electives,
  • Provide ICU-heavy training,
  • House EM, critical care, or hospitalist fellowships.

Tier 3: Bridge Positions

• Prelim Internal Medicine or Transitional Year in:
  • Places with EM residencies or combined programs,
  • Institutions where you can build relationships and gain strong U.S. references for a future EM or EM–IM application.

Tier 4: Last‑Resort Options

• Programs outside EM/IM that still build acute care skills (Prelim surgery, anesthesiology, etc.), if absolutely necessary and aligned with your tolerance for future re‑application.

The critical message: Don’t wait until Monday of Match Week to decide how far down this list you’re willing to go. Decide now.

Step 4: Prepare Targeted Application Materials in Advance

Your ERAS documents must be SOAP-ready with minimal last-minute changes.

1. Personal Statement Variants

   • One primary PS emphasizing EM–IM vision with flexibility:
     • “My long-term goal is a career that bridges emergency and internal medicine practice…”
   • A version tailored to IM emphasizing:
     • Inpatient and critical care interest,
     • Continuity, chronic disease management, and acute inpatient care.
   • A version tailored to EM emphasizing:
     • Acute care, resuscitation, undifferentiated patients, and system-based practice.

2. CV and Experiences

   • Update all significant activities, especially:
     • EM clerkships,
     • IM ward rotations,
     • ICU experiences,
     • Research or QI in acute care.

3. Letters of Recommendation

   • Aim for:
     • At least one strong IM letter,
     • At least one strong EM letter,
     • Preferably from U.S. academic faculty.
   • Ensure they are uploaded and assigned appropriately in ERAS.

4. Program‑Specific Notes

   • Prepare a brief template you can quickly personalize for programs during SOAP that explains:
     • Why you’re interested in their EM or IM program,
     • How your EM–IM combined interest still fits their categorical pathway,
     • Why you’re a realistic, eager, and committed candidate.

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Match Week Logistics: Executing a High‑Intensity SOAP Strategy

When Monday of Match Week arrives, you must be ready to move fast, especially as an IMG.

Monday Morning: Confirm Status and Eligibility

At 10:00 AM ET:

1. Log into NRMP R3:

   • If you’re Unmatched or Partially Matched and SOAP-eligible, you’ll see confirmation.

2. Confirm:

   • ECFMG certification status,
   • Visa plans and deadlines,
   • Whether any prior issues (exams, documents, credentials) might affect July 1 eligibility.

If anything is unclear (especially for IMGs with pending ECFMG items), contact ECFMG immediately.

Monday Midday: Analyze the List of Unfilled Programs

When the list of unfilled programs appears:

1. Filter by Specialty

   • First, check for any EM–IM combined listings.
     • These are rare; most years, you may find none.
   • Then, look at:
     • Emergency Medicine,
     • Internal Medicine (categorical),
     • Preliminary IM,
     • Transitional Year.

2. Filter by IMG‑friendliness

   • Look at:
     • Whether they sponsor visas (J‑1, H‑1B),
     • Whether historically they have accepted IMGs (public websites, known IMG residency guides, or prior data),
     • Geographic regions with historically higher IMG acceptance (e.g., certain Northeast, Midwest, or community hospitals).

3. Prioritize EM– or IM‑aligned Programs

   • Any EM or IM program at an institution with a known EM–IM combined track is particularly valuable, even if your SOAP spot is categorical.

Building Your SOAP Application List (Up to 45 Programs)

You are allowed a maximum of 45 SOAP applications across all rounds. Use them strategically:

Strategy for an IMG Targeting EM–IM

1. Top 5–10 Slots

   • High‑priority EM or IM programs that:
     • Are academically strong,
     • Have combined programs or dual pathways,
     • Are known for critical care/hospitalist or ED‑based research.
   • Include any EM–IM combined spots if they appear.

2. Next 15–20 Slots

   • Solid categorical IM or EM programs:
     • Known to accept IMGs and/or sponsor visas,
     • Acceptable geography and training environment,
     • Good volume in ED and ICU.

3. Remaining Slots

   • Prelim IM or transitional year programs in:
     • Institutions with EM programs,
     • Large teaching centers with strong acute care exposure.

4. Special Considerations for Partial Matches

   • If you’re partially matched (e.g., matched to an advanced position without a prelim year), prioritize prelim IM or transitional year programs that fill the missing component.
   • Do not sacrifice long-term EM–IM goals completely, but ensure you fulfill the immediate requirement to start training.

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Interview Performance During SOAP: Standing Out as an IMG

SOAP interviews move quickly—often same-day scheduling, with short notice and tight time windows. You must be prepared to communicate your story clearly and efficiently.

Core Message: “I’m Committed, Flexible, and Realistic”

Program directors during SOAP want:

• Residents who can start on time,
• Trainees who will stay and complete the program,
• Applicants who understand the specialty and training environment.

As an IMG targeting EM–IM combined training, center your message on:

1. Genuine Interest in Their Specialty (EM or IM)

   • Even if EM–IM is your long-term dream, never sound like their categorical program is only a backup or consolation prize.
   • Example framing:
     • “My long-term vision is to practice at the interface of acute care and comprehensive internal medicine. Your internal medicine program’s strong critical care and complex inpatient exposure will be an ideal foundation for that type of career.”

2. Alignment with Their Program Strengths

   • Study each program’s website or available data quickly.
   • Emphasize:
     • ED volume, ICU rotations, co-management of complex medical ED patients,
     • Research, QI, or teaching interests that align with your background.

3. IMG-Specific Professionalism

   • Demonstrate:
     • Clear communication skills,
     • Cultural competence,
     • Familiarity with U.S. training norms,
     • Understanding of visa timelines (if applicable).

Common SOAP Interview Questions and Strong Sample Angles

1. “Why were you not matched in the Main Match?”

   • Avoid blame or negativity.
   • Focus on:
     • Specialty competitiveness,
     • Late improvements (e.g., Step 2 score, extra USCE),
     • How you’ve addressed prior weaknesses.
   • Example:
     • “Emergency Medicine and combined EM–IM tracks are highly competitive, and as an IMG, I recognize my path is more challenging. Over this year I have strengthened my application with additional U.S. rotations, Step 2 improvement, and more robust letters. SOAP gives me the chance to pursue closely aligned training in your internal medicine program, which I would be honored to join.”

2. “Why our program?”

   • Have 2–3 specific reasons:
     • EM rotation availability, ICU strength, patient population, academic environment, prior IMGs’ success.
   • Tie explicitly to EM–IM interests without making them feel “second choice.”

3. “If you receive multiple offers, how will you decide?”

   • Emphasize:
     • Fit, training quality, ability to grow in EM–IM–aligned directions,
     • Commitment to staying and contributing long term.

4. “Will you be satisfied in a categorical IM or EM program if combined training isn’t possible?”

   • Be honest but positive:
     • “Yes. My core passion is acute and complex adult medicine. A strong categorical IM program like yours provides an excellent platform for my long-term goals in hospitalist, critical care, and emergency care interfaces. I would be fully committed to seeing this training through and building a career from here.”

Practical Interview Tips for IMGs

• Set up a professional environment:
  • Good lighting, neutral background, no interruptions.
• Have a note sheet ready:
  • Program name, key strengths, reasons you like them, questions to ask.
• Prepare concise stories:
  • One EM-focused, one IM-focused, one cross‑disciplinary that shows:
    • Leadership,
    • Resilience,
    • Teamwork in acute care,
    • Cultural humility and communication.

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Accepting Offers and Post‑SOAP Planning

SOAP rounds move quickly. As an IMG, you may feel pressured when an offer appears because visa and ECFMG constraints make opportunities feel rarer. Balance urgency with strategy.

When You Receive an Offer

Ask yourself:

1. Does this program:
   • Sponsor my required visa?
   • Provide training in EM or IM (or a related prelim/transitional year) consistent with my long-term EM–IM aspirations?
2. Am I willing to fully commit to this program if I accept?
3. Have I clarified:
   • Start date,
   • Orientation timing,
   • Any special institutional onboarding requirements for IMGs?

If the answers are positive, strongly consider accepting. Declining in hopes of a “better” offer in a later round is risky—especially as an IMG.

After Accepting a SOAP Position

1. Confirm Documentation

   • ECFMG certificate,
   • Medical school diploma and transcripts,
   • Immunizations, background checks, and other onboarding.

2. Align Training With EM–IM Interests

   • Discuss with your future program director (after SOAP is complete and the dust settles):
     • Interest in EM or EM‑adjacent experiences,
     • ICU and acute care electives,
     • Research in sepsis, ED throughput, critical care, or health systems.

3. Long-Term Options

   • If you are in categorical IM:
     • Maximize ICU, ED consults, and acute care rotations.
     • Explore future EM fellowships (e.g., for IM graduates where available), hospitalist roles with ED coverage, or critical care training.
   • If you are in categorical EM:
     • Seek internal medicine-heavy rotations, multi-day admissions, and longitudinal follow-up.
   • If you are in a prelim or transitional year:
     • Build the strongest possible U.S. track record, letters, and relationships for future reapplication to EM–IM, EM, or IM.

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Final Checklist: SOAP Preparation for an IMG Targeting EM–IM Combined

2–4 Months Before Match Week

• Realistically assess your chance of matching in EM–IM combined or EM.
• Define your tiered backup plan (EM, IM, prelim, transitional).
• Prepare multiple personal statement versions:
  • EM–IM / EM-focused,
  • IM-focused.
• Ensure all LoRs, especially U.S. EM and IM, are uploaded.
• Clarify your visa strategy and confirm programs you applied to historically sponsor IMGs.

1 Month Before Match Week

• Learn the exact SOAP timeline for the year (NRMP).
• Set up reliable technology for rapid email, ERAS access, and video interviews.
• Draft a brief SOAP pitch for EM programs and another for IM programs.
• Review common interview questions and rehearse 60–90 second responses.

Week Before Match Week

• Clear your schedule Monday–Thursday to be fully available.
• Organize a document to track:
  • Unfilled programs,
  • Applications sent,
  • Interview invites and scheduling,
  • Ranking preference among programs.
• Ensure your phone, email, and ERAS contact information are correct and active.

During SOAP

• Log in on Monday at 10:00 AM ET; confirm unmatched/partially matched status.
• Quickly scan unfilled list for EM–IM, EM, IM, prelim IM, transitional.
• Build and submit up to 45 applications strategically.
• Respond immediately to interview requests; keep calendar open.
• Keep your EM–IM story consistent but program‑focused.
• When offers come, confirm visa and commitment level, then accept promptly if aligned.

Taking SOAP seriously and preparing early transforms it from a chaotic last-chance scramble into a structured, strategic extension of your IMG residency guide plan—especially if your dream is a life at the intersection of Emergency Medicine and Internal Medicine.

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FAQ: SOAP Preparation for IMGs in EM–IM Combined Pathways

1. As an IMG, should I still aim for EM–IM combined during SOAP, or focus only on EM or IM?
You should look for EM–IM combined if any openings appear, but realistically, openings are rare. For most IMGs, the best SOAP strategy is to:

• Prioritize categorical EM or IM spots that support your long-term EM–IM‑style career,
• Choose programs with strong ED, ICU, and complex inpatient exposure,
• Use your training to pivot toward EM–IM‑aligned roles (e.g., hospitalist in high-acuity settings, critical care, future EM fellowship if available).

2. Do programs see that I was unmatched when I apply through SOAP residency?
Programs know that SOAP applicants are unmatched or partially matched, but they see your ERAS application much like in the main season. You do not need to over‑explain your unmatched status; instead, acknowledge the competitiveness of the field and emphasize how you have grown and why you are a good fit for their program now.

3. How should I mention my EM–IM combined interest without sounding like their program is a backup?
Frame EM–IM as a career direction, not a rigid requirement:

• Highlight overlapping skills: acute care, complex internal medicine, patient safety.
• Emphasize that their categorical EM or IM training is an excellent foundation for your career vision.
• Make it clear you would be fully committed to completing their program and see multiple satisfying career pathways from it.

4. What is SOAP preparation most IMGs miss that hurts their chances?
Common mistakes include:

• Waiting until Match Week to learn what is SOAP and how it works,
• Failing to prepare separate EM and IM personal statements,
• Not understanding visa limitations or not clarifying if unfilled programs sponsor visas,
• Applying to programs nonspecifically instead of building a tiered, strategic list,
• Entering SOAP without practiced, concise explanations for being unmatched and for their genuine interest in EM or IM.

By anticipating these issues and preparing thoroughly, you maximize your chances of turning SOAP into a solid, career‑building opportunity—even when EM–IM combined spots themselves are limited.