Essential SOAP Preparation Guide for IMGs in Medicine-Pediatrics Residency

Understanding SOAP for the IMG Applying to Medicine-Pediatrics

Supplemental Offer and Acceptance Program (SOAP) week can feel intense and overwhelming, especially as an international medical graduate (IMG) aiming for the highly specialized field of Medicine-Pediatrics (Med-Peds). But with deliberate SOAP preparation and a clear strategy, it can also be an opportunity to secure a strong training position—even if the initial Match results were disappointing.

This IMG residency guide focuses specifically on SOAP preparation for international medical graduates interested in Med-Peds or closely related pathways. You will learn:

• What SOAP is and how it works during Match Week
• How Med-Peds fits into the SOAP landscape
• How to analyze your profile and build a realistic SOAP strategy
• How to prepare all documents and communications before Match Week
• How to adapt quickly when SOAP opens and positions are posted

Throughout, the emphasis is on practical, step-by-step planning tailored to IMG needs.

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1. What Is SOAP and How Does It Work in the Med-Peds Context?

Before you can prepare effectively, you must clearly understand what is SOAP and how it functions.

1.1 SOAP: The Core Concept

The Supplemental Offer and Acceptance Program (SOAP) is an NRMP-managed process during Match Week that allows eligible unmatched or partially matched applicants to apply to and potentially secure unfilled residency positions.

Key points:

• Runs during Match Week (Monday–Thursday)
• Uses ERAS for applications and NRMP’s R3 system for offers/acceptances
• Structured in rounds of offers (usually 3–4)
• Only applicants who are SOAP-eligible and registered with NRMP can participate

You are SOAP-eligible if (summarized; always verify on NRMP site for the current year):

• You registered for the Main Residency Match
• You are fully unmatched or partially matched (e.g., advanced but no preliminary) by Monday of Match Week
• You have passed USMLE/COMLEX exams required for ECFMG certification (for IMGs)
• You meet eligibility rules for the Main Match

1.2 Med-Peds and SOAP: What to Expect

Combined Internal Medicine–Pediatrics (Med-Peds) is a popular, relatively competitive specialty. Many Med-Peds positions fill in the main Match, and there are fewer unfilled Med-Peds spots compared to categorical Internal Medicine or Pediatrics.

Implications for an IMG:

• Do not rely on SOAP for Med-Peds positions alone; there may be zero or very few unfilled Med-Peds spots.
• Your SOAP strategy must be broader, including categorical Internal Medicine, categorical Pediatrics, preliminary Medicine or Transitional Year if appropriate.
• A Med-Peds–oriented applicant can still build a strong career in combined adult and pediatric care by:
  • Matching in Pediatrics and later doing an adult-focused fellowship (e.g., Allergy/Immunology, Rheumatology)
  • Matching in Internal Medicine and choosing a child-inclusive subspecialty or practicing broad general medicine
  • Considering programs with strong combined Medicine-Pediatrics culture (e.g., large academic centers with Med-Peds departments, even if you match to categorical IM or Peds)

Your SOAP preparation should therefore anticipate multiple realistic pathways to reach your long-term Med-Peds style career, not just a classic 4-year Med-Peds slot.

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2. Strategic Pre–Match Week Planning for IMGs Interested in Med-Peds

Effective SOAP preparation begins months before Match Week. The more you do in advance, the calmer and more flexible you will be when SOAP opens.

2.1 Honest Assessment of Your IMG Profile

Before you can design a SOAP strategy, you must understand where you stand. Consider:

• Exam scores: USMLE Step 1 (if applicable), Step 2 CK, Step 3 (if taken)
• Attempts: Any exam failures or multiple attempts
• ECFMG certification status: Completed, pending, or not yet eligible
• Year of graduation (YOG): Many programs prefer recent graduates
• Clinical experience in the U.S.:
  • Med-Peds rotations?
  • Internal Medicine or Pediatrics electives/sub-internships?
  • Inpatient vs outpatient exposure?
• Letters of Recommendation (LoRs):
  • How many from U.S. attendings?
  • Any from Med-Peds faculty/program directors?
• Red flags: Gaps, failures, professionalism concerns, incomplete documentation

This assessment will drive how broad or narrow your SOAP application list should be.

Example:

• IMG, YOG 2021, Step 2 CK 237, one Pediatrics elective in the U.S., no Med-Peds rotation, ECFMG certified.
  • Reasonable SOAP targets: Categorical Pediatrics (community hospitals), categorical Internal Medicine (mid-tier/community), some preliminary Medicine, and possibly any unfilled Med-Peds positions if they appear—but not exclusively Med-Peds.

2.2 Defining Your Med-Peds–Oriented Career Goal

Ask yourself:

• Do you want to practice as a dual-certified Med-Peds physician, or
• Are you primarily drawn to longitudinal care across the lifespan and complex chronic disease, which might be achievable through other routes?

For many IMGs, the true career goal is:

• Caring for both adults and children
• Managing medically complex or chronically ill patients
• Working in academic or interdisciplinary primary care

These can be reached via:

• Med-Peds residency (ideal if available)
• Pediatrics with additional adult-related training or collaboration
• Internal Medicine with pediatric exposure (e.g., adolescent medicine, adult survivors of childhood disease clinics, global health roles)

Clarifying this gives you flexibility during SOAP. If no Med-Peds positions are open, you will still have a coherent Plan B and Plan C.

2.3 Building Your “SOAP Universe” of Acceptable Programs

You cannot see the list of unfilled positions until noon ET on Monday of Match Week, but you can pre-identify program types and geographic regions you find acceptable. This avoids emotional decision-making under time pressure.

Consider:

• Geography:
  • Are you willing to relocate anywhere in the U.S. for training?
  • Are there states you truly cannot go to (family reasons, visa support, etc.)?
• Visa policies:
  • Must the program sponsor J-1 or H-1B?
  • Are you open to J-1 only?
• Program type:
  • University vs community vs community-based university-affiliated programs
  • Safety-net hospitals with high needs vs more resourced systems

For SOAP, many IMGs succeed by being geographically and program-type flexible within safe and reasonable limits.

Action step:
Make a document with two sections:

1. Must-have criteria (e.g., J-1 visa sponsorship, accredited Med-Peds/IM/Peds program)
2. Flexible criteria (e.g., location preference, size of the city, academic vs community)

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3. Document and Profile Preparation Before SOAP Week

By the time SOAP opens, you should not be editing major sections of your ERAS application. Your focus should be on strategy, communication, and timely responses. That requires early document preparation.

3.1 Review and Optimize Your ERAS Application for a Broader Audience

Your original ERAS application might have been heavily tailored to Med-Peds. For SOAP, it must appeal to:

• Med-Peds programs (if any unfilled slots exist)
• Categorical Internal Medicine
• Categorical Pediatrics
• Possibly preliminary Medicine or Transitional Year

Review:

• Personal Statement:

  • Does it mention only Med-Peds, or does it describe your passion for lifespan care, chronic disease management, and continuity of care?
  • Better: highlight themes that are valued in all three: Med-Peds, IM, and Peds (e.g., complex patients, teamwork, evidence-based care, communication with families).

• Experiences and Activities:

  • Emphasize leadership, research, quality improvement, and clinical experiences relevant to Med-Peds, IM, and Pediatrics.
  • Clarify roles in pediatric vs adult settings.

• Meaningful Experiences:

  • Could any be reframed to show your adaptability to Internal Medicine or Pediatrics settings?

If your ERAS personal statement is too narrow, consider preparing one or two alternate statements for SOAP:

• One emphasizing Internal Medicine + Med-Peds interests
• Another emphasizing Pediatrics + Med-Peds interests

You can upload new personal statements in ERAS and assign them selectively during SOAP.

3.2 Letters of Recommendation (LoRs): Maximize Their Impact

Strong LoRs are especially important for the IMG residency guide to success during SOAP.

Ideally, you will have:

• At least 3 recent, specialty-relevant letters, preferably from U.S. attendings
• At least one letter in Internal Medicine and one in Pediatrics
• A Med-Peds letter if you had a combined rotation (great bonus, not mandatory)

SOAP preparation tips for LoRs:

• Confirm all LoRs are uploaded and assigned in ERAS well before Match Week.
• If you are missing a specialty-specific letter (e.g., only Peds, no IM), consider whether you can obtain a general “adult medicine” letter from an internist you worked with (if timeline still allows).
• During SOAP, avoid changing LoRs unless absolutely necessary; it consumes time and can cause errors.

3.3 Curriculum Vitae and Supporting Documents

Even though ERAS contains much of your data, some programs may request an updated CV or supplemental document by email during SOAP (especially for non–Electronic SOAP opportunities later in the year).

Prepare:

• A clean, updated CV focusing on:
  • Clinical experience (U.S. and home country)
  • Research/QI relevant to adult or pediatric medicine
  • Leadership and teaching roles
• A brief, ready-to-use SOAP introduction email template (more on this below)

3.4 Clarify Your Visa and Licensing Readiness

Many programs worry about delays with IMGs. To reassure them:

• Ensure ECFMG certification status is clear in your ERAS and CV.
• Keep digital copies of:
  • Passport
  • USMLE score reports
  • ECFMG certificate (if issued)
• Know your visa options and limitations well enough to answer quickly:
  • J-1 only vs H-1B eligible (Step 3 required, state rules, etc.)

Programs prefer candidates who seem administratively low-risk in the stressful atmosphere of SOAP.

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4. SOAP Week Timeline and Tactics for the Med-Peds–Oriented IMG

When Match Week starts, your SOAP preparation translates into decisive action.

4.1 Monday Morning: “Did I Match?” Email and Eligibility

On Monday of Match Week (usually 11:00 a.m. ET), you receive an NRMP email:

• “You are unmatched” → Full participation in SOAP is possible
• “You are partially matched” → May still qualify (e.g., you matched an advanced spot but not a prelim year, or vice versa)

Immediately:

1. Log into NRMP’s R3 system and confirm your SOAP eligibility status.
2. Review NRMP instructions for that year’s SOAP schedule to verify times and rules.

4.2 Monday Noon: Unfilled Positions List and Program Targeting

At approximately 12:00 p.m. ET, the list of unfilled programs and positions becomes available (via NRMP). This is the most critical hour for your Med-Peds-oriented SOAP strategy.

Steps:

1. Scan for Med-Peds positions first.
   • If any are available, prioritize them only if you are realistically competitive (scores, YOG, visa, clinical experience).
2. Identify:
   • Categorical Internal Medicine positions
   • Categorical Pediatrics positions
   • Preliminary Medicine and Transitional Year (TY) positions
3. Use your pre-made must-have vs flexible criteria to select which programs to apply to.

You will have a limit on the number of programs you may apply to through SOAP (commonly 45 unique programs, but verify each year’s rules). In practice:

• Consider allocating:
  • A small portion to any realistic Med-Peds positions
  • A larger share to categorical IM and Pediatrics (where long-term Med-Peds-style careers are still feasible)
  • A minority to prelim/TY positions if you are open to multi-step training paths

4.3 Application Submission Strategy

When the ERAS SOAP portal opens for applications:

• Assign the most appropriate personal statement to each program group:
  • Med-Peds → Med-Peds-focused or combined IM-Peds statement
  • IM → IM-oriented statement
  • Peds → Peds-oriented statement
• Double-check:
  • LoRs assigned correctly
  • USMLE/ECFMG information complete
  • No glaring typos or missing fields

Submit applications early in the window; programs typically begin reviewing immediately.

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5. Communication, Interviews, and Offers During SOAP

How you communicate during SOAP can strongly influence program decisions, especially as an IMG.

5.1 SOAP Communication Rules

The NRMP has clear rules about what programs and applicants can and cannot do during SOAP. These change slightly year to year; always verify the official guidance.

General concepts:

• Programs may initiate contact (usually via email or phone) to schedule short interviews.
• Applicants should not initiate contact with programs before they receive permission (e.g., via ERAS contact info release), depending on current rules.
• Verbal promises are not binding; only NRMP-generated offers and acceptances are binding.

Stay current by reading NRMP’s SOAP communications rules each season.

5.2 Preparing for SOAP Interviews

SOAP interviews are typically:

• Brief (10–20 minutes)
• Conducted by phone or video
• Focused on immediate impressions and clarifying questions

As an IMG targeting Med-Peds or related fields, anticipate questions such as:

• “You initially applied to Med-Peds. Why are you interested in our Internal Medicine/Pediatrics program now?”
• “How do you see your career developing if you match into our categorical program rather than Med-Peds?”
• “What strengths do you bring as an IMG and as someone with Med-Peds-type interests?”

Prepare short, structured answers, for example:

Example answer (for a Pediatrics program):

“My original interest in Med-Peds comes from wanting to care for medically complex patients across the lifespan and from enjoying both adult and pediatric medicine. However, Pediatrics has always been a core passion for me. If I match with your program, I aim to build a strong foundation as a pediatrician, with a focus on chronic disease and transitions of care for adolescents into adult systems. My Med-Peds exposure will help me collaborate effectively with Internal Medicine colleagues and advocate for smooth transitions for our patients.”

Have 3–4 key stories ready that demonstrate:

• Teamwork and communication
• Managing complex patients
• Adaptability (important for SOAP situations)
• Commitment to learning and quality care

5.3 Email Templates and Professional Tone

When programs contact you or allow direct communication, use concise, professional emails. Example:

Subject: SOAP Applicant – [Your Name], [AAMC ID], Interest in [Program Name]

Dear Dr. [Last Name] / Program Director,

I am an international medical graduate originally oriented toward Medicine-Pediatrics who is now participating in SOAP. I have applied to your [Internal Medicine/Pediatrics] residency program via ERAS and am writing to express my strong interest.

My clinical background includes [brief summary: US rotations, exam performance, relevant strengths]. I am particularly drawn to your program because [specific reasons: patient population, teaching structure, Med-Peds presence, academic resources].

I would be grateful for the opportunity to speak with you or a member of your team if you are conducting interviews during SOAP.

Thank you very much for your time and consideration.

Sincerely,
[Name], MD
[AAMC ID]
[Phone] | [Email]

Pre-writing this template is a key piece of SOAP preparation.

5.4 Understanding Offer Rounds and Acceptance

SOAP typically has multiple offer rounds (e.g., 3–4) over two days. Process overview:

1. Programs submit a list of preferred applicants for each unfilled position.
2. NRMP runs an algorithm and issues offers to selected applicants at scheduled times.
3. You may:
   • Accept only one offer (binding)
   • Reject offers or let them expire (if you are hoping for others in future rounds)

For an IMG, the risk of holding out for a “better” offer can be high. General guidance:

• If you receive a solid categorical IM or Peds position in a program that meets your must-have criteria (visa, accreditation, reasonable environment), strongly consider accepting it—especially as an IMG without a safety net.
• Use caution if declining reasonable offers hoping for rare Med-Peds positions or specific locations.

When you accept an offer:

• The SOAP process ends for you; you are matched into that position.
• You must promptly stop all additional interviewing or exploring other offers.

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6. Long-Term Med-Peds Career Thinking Beyond SOAP

Even if SOAP does not yield a classic Med-Peds residency, your Med-Peds-oriented interests can still shape your career.

6.1 If You Match Into Internal Medicine

You can:

• Focus on adolescent medicine, transition care for pediatric patients with chronic diseases, and adult survivors of childhood-onset conditions.
• Seek electives that collaborate with Pediatrics or Med-Peds departments.
• Pursue fellowships that span age groups (e.g., Allergy/Immunology, Rheumatology, Infectious Diseases, Palliative Care).
• Engage in research or quality improvement projects related to transition of care between pediatrics and adult medicine.

6.2 If You Match Into Pediatrics

You can:

• Develop expertise in complex care pediatrics, adolescent medicine, or pediatric subspecialties with strong adult interfaces (e.g., congenital heart disease, cystic fibrosis).
• Collaborate with adult medicine teams in transition of care clinics.
• In large academic centers, some attending roles work closely with Med-Peds faculty, giving you interdisciplinary experience.

6.3 If You Do Not Match Through SOAP

Not matching after SOAP is deeply difficult, especially for an IMG. However, you can still use this experience constructively to strengthen your next cycle:

• Request feedback (where possible) from physicians and mentors who know your application.
• Improve:
  • US clinical experience (ideally IM, Peds, or Med-Peds)
  • Exam performance (e.g., Step 3, if relevant)
  • Research or QI experience
  • Communication skills and interview performance
• Consider a postdoctoral research position or clinical observerships in Med-Peds–friendly institutions.

You can re-apply in the next Match with:

• A revised application narrative (from “just Med-Peds” to well-argued Med-Peds/IM/Peds options)
• Stronger letters and more targeted program selection

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FAQs: SOAP Preparation for IMGs in Medicine-Pediatrics

1. As an IMG, should I apply only to Med-Peds programs during SOAP?
No. The medicine pediatrics match fills most Med-Peds spots in the main Match, leaving few or no positions for SOAP. For effective SOAP preparation, plan to apply widely to categorical Internal Medicine and Pediatrics programs, plus any realistic Med-Peds positions that appear. This increases your chances of securing a training position that still supports a Med-Peds-style career.

2. How can I explain my Med-Peds interest to Internal Medicine or Pediatrics programs during SOAP?
Frame Med-Peds not as a separate specialty you “missed,” but as an expression of your passion for longitudinal care, complex patients, and continuity across life stages. Emphasize how these same interests make you a strong candidate for Internal Medicine or Pediatrics and highlight your flexibility: you are prepared to build a meaningful career through their pathway while collaborating with the other side (adult or pediatric) throughout your career.

3. What is the best way for an IMG to stand out in SOAP interviews?
Be concise, prepared, and reliable. Have clear, practiced answers about:

• Why you are interested in their program specifically
• How your IMG background adds value (resilience, cross-cultural communication, broad clinical exposure)
• How you handled challenges, including the disappointment of not matching
  Demonstrate strong English communication, professionalism, and a realistic understanding of visa and licensing issues. Program directors under soap residency time pressure appreciate applicants who are straightforward, calm, and well-prepared.

4. Does participating in SOAP hurt my chances of getting Med-Peds in the future?
Not necessarily. If you secure a categorical Internal Medicine or Pediatrics position and excel, you can still shape a career similar to Med-Peds through fellowships, transition-of-care work, or cross-disciplinary practice. If you do not match during SOAP and reapply the following year, a well-explained gap year filled with meaningful clinical, research, or educational work in IM/Peds/Meds-Peds can strengthen your application. Programs mainly want to see growth, resilience, and continuous commitment to internal medicine, pediatrics, or combined care.

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Thoughtful SOAP preparation gives you agency during a stressful week. As an international medical graduate pursuing a Med-Peds–oriented career, flexibility and clarity of purpose are your greatest assets. By planning early, broadening your options strategically, and communicating professionally, you can transform SOAP from a last-minute scramble into a structured, opportunity-focused phase of your residency journey.