Essential SOAP Preparation Guide for IMGs in Cardiothoracic Surgery Residency

Understanding SOAP as an IMG Targeting Cardiothoracic Surgery

The Supplemental Offer and Acceptance Program (SOAP) is the NRMP’s structured process that allows eligible unmatched or partially matched applicants to obtain unfilled residency positions after the main Match. For an international medical graduate (IMG) with aspirations in cardiothoracic surgery, understanding SOAP deeply—and preparing long before Match Week—is critical.

Before anything else, you must be clear on what is SOAP:

• SOAP timeframe: Occurs during Match Week (usually Monday–Thursday before Match Day).
• Who participates: Eligible unmatched or partially matched applicants who have registered for the NRMP Match and meet all SOAP requirements.
• What SOAP is not: It is not a second full application season and it is not a negotiation process. It’s a rapid, rule-driven, mostly electronic process with strict communication restrictions.

For an IMG focused on cardiothoracic surgery, SOAP has unique implications:

• Direct cardiothoracic surgery residency spots for IMGs are rare in SOAP. Most cardiothoracic surgeons in the U.S. train via:
  • General Surgery residency → Cardiothoracic Surgery fellowship, or
  • Integrated 6-year cardiothoracic surgery (I-6) programs (very competitive, rarely unfilled).
• Your SOAP strategy must balance:
  • Long-term goal: heart surgery training and an eventual cardiothoracic surgery career
  • Short-term realism: what positions will actually be available in SOAP, and how they can still keep you on a path toward cardiothoracic surgery.

This IMG residency guide will walk you through SOAP preparation specifically tailored to cardiothoracic surgery–oriented IMGs, covering strategy, documentation, communication, and mental readiness.

---

Step 1: Pre-Match Assessment – Are You at Risk of Needing SOAP?

SOAP preparation starts months before Match Week, especially for an international medical graduate. Do not wait until you find out you are unmatched.

1.1 Know Your Risk Profile

For IMGs aiming for a surgical path (including cardiothoracic surgery), common risk factors for going into SOAP include:

• Limited or no U.S. clinical experience (USCE), especially in surgery
• USMLE scores:
  • Step 1: Pass only (no numeric score) is now common, but low Step 2 CK scores (<230–235) may reduce competitiveness in surgery
• Gaps after graduation (>3–5 years since medical school without continuous clinical/academic activity)
• Weak or generic letters of recommendation, only from non-U.S. settings
• Overly narrow rank list, e.g., only a few highly competitive programs (like I-6 cardiothoracic surgery) and virtually no backups
• Limited research, especially in cardiothoracic or surgical fields

If several of these apply to you, you must assume SOAP is a realistic possibility and start planning.

1.2 Map Your Long-Term Cardiothoracic Trajectory

Because cardiothoracic surgery residency spots are scarce, you must understand alternative but viable roads to heart surgery training:

• Preferred path for most IMGs:
  • General Surgery residency (categorical) → Cardiothoracic Surgery fellowship (3 years)
• Other possible stepping stones:
  • Preliminary Surgery year → Re-apply to General Surgery (categorical)
  • Internal Medicine with strong cardiology/critical care focus → later transition to cardiovascular fellowships (though not classic cardiothoracic surgery route)
  • Research years in cardiothoracic surgery → stronger re-application profile

During SOAP, realistic options to sustain a future cardiothoracic surgery–aligned profile often include:

• General Surgery (categorical) – ideal but may be limited in SOAP
• Preliminary Surgery positions – common in SOAP; important gateway
• Transitional Year or Internal Medicine – can maintain clinical activity while you improve your application

Your first SOAP preparation task is to realize: the goal of SOAP is to secure a viable position, not necessarily your final destination specialty. But you can and should choose positions that keep the cardiothoracic door open.

---

Step 2: Understanding SOAP Mechanics and Rules

A strong SOAP preparation strategy requires mastery of the rules. Missteps can disqualify you.

2.1 Basic SOAP Eligibility Checklist

You are generally eligible for SOAP if:

• You are registered for the NRMP Match
• You are eligible to enter graduate medical education (e.g., ECFMG certified or will be by program start date, depending on rules that year)
• You did not match to any position, or you are partially matched (e.g., matched to an advanced position without a preliminary year)
• You did not withdraw from the Match after ROL certification
• You have no binding Match commitment and are not already matched in another NRMP Match (e.g., prior year)

Confirm specific eligibility criteria for the current year on NRMP and ECFMG websites.

2.2 What Happens During Match Week and SOAP

• Monday at 10:00 AM ET:
  • You learn if you are Matched, Partially Matched, or Unmatched.
  • Unfilled positions list becomes available to SOAP-eligible applicants at 11:00 AM ET (through ERAS).
• Monday–Thursday:
  • Several application and offer rounds take place.
  • You apply via ERAS (not NRMP), but positions are filled through the NRMP SOAP system.

Communication rules:

• Before programs contact you:
  • You may not initiate contact with programs about SOAP positions.
• During SOAP:
  • Programs can contact you (phone, email, video) if you have applied to their position.
  • You should respond promptly and professionally; you may not solicit positions from programs you did not apply to.
• All offers and acceptances occur through NRMP, not informally.

Violations can jeopardize your participation.

---

Step 3: Technical SOAP Preparation Before Match Week

A core aspect of SOAP preparation is making sure your ERAS application is SOAP-ready long before Match Week.

3.1 Optimize Your ERAS Content for Surgical Appeal

Even if you applied broadly, refine your ERAS for a surgery-focused narrative that aligns with eventual heart surgery training:

• Personal Statement Strategy

  • Primary statement for the Match: Cardiothoracic surgery–oriented (or general surgery with clear CT interest).
  • For SOAP: Prepare 2–3 alternative personal statements well in advance:
    1. General Surgery–focused (with articulated interest in cardiothoracic surgery)
    2. Preliminary Surgery–focused (emphasizing work ethic, operative interest, adaptability)
    3. Transitional Year/Internal Medicine–focused (emphasizing foundation for future cardiology, critical care, or surgical path)

  You will not have time during Match Week to write them from scratch. Draft and upload them early, labeled clearly for fast selection.

• CV/Experiences Emphasis

  • Highlight:
    • Surgical rotations, especially cardiac or thoracic surgery
    • Surgical skills exposure (even observation)
    • Cardiovascular or thoracic research, QI projects, or case reports
    • Procedural competencies (central lines, chest tubes, ICU skills, etc.)
  • Reorder experiences in ERAS so surgery and cardiothoracic content appears at the top where appropriate.

• USMLE and Exams

  • Ensure all score reports are correctly uploaded.
  • If you have stronger Step 2 CK performance, subtly direct attention to it in your experiences or personal statement narrative.

3.2 Letters of Recommendation (LoRs) Ready for SOAP Scenarios

As an IMG, strong letters are especially important:

• At least 1–2 letters from U.S. surgeons, ideally:
  • General surgeons
  • Cardiothoracic or vascular surgeons
• Additional letters from:
  • ICU/Anesthesia/ cardiology if relevant to cardiothoracic path
  • Research mentors in cardiothoracic or surgical fields

Upload all letters early. During SOAP, you can choose which letters to assign to which applications—including different combinations for preliminary surgery vs internal medicine.

3.3 Program and Specialty Research in Advance

You cannot predict which specific programs will appear on the unfilled list, but you can prepare a tiered target list of specialties:

1. Top priority for CT trajectory:
   • Categorical General Surgery
   • Categorical Integrated Cardiothoracic Surgery (very rare; still, know them)
2. Second tier (bridge positions):
   • Preliminary General Surgery
   • Preliminary positions with strong ICU exposure in surgery-heavy hospitals
3. Third tier (foundation and continuity):
   • Transitional Year programs with strong surgical exposure
   • Internal Medicine programs with robust cardiology/cardiac ICU services
   • Anesthesiology prelim/PGY-1 positions if available

Before Match Week:

• Review requirements, visa policies (J-1/H-1B), and IMG friendliness of potential programs.
• Identify geographic flexibility—SOAP moves quickly; you must be willing to relocate.

Create a simple spreadsheet to log:

• Specialties you would accept in SOAP
• Minimum criteria you require (visa eligibility, ACGME accreditation, etc.)
• Preferred characteristics (academic vs community, CT surgery presence, etc.)

This prevents panic-driven decisions later.

---

Step 4: Strategizing Your SOAP Applications as an IMG Interested in Cardiothoracic Surgery

Once Match Week starts and you learn you are unmatched or partially matched, your SOAP strategy must be calm, fast, and methodical.

4.1 Interpreting the Unfilled Positions List

The Unfilled Positions List will be categorized by specialty and program.

For a cardiothoracic surgery–oriented IMG, assess in this order:

1. Categorical General Surgery spots
   • Apply broadly to any program that:
     • Accepts IMGs or is historically IMG-friendly
     • Sponsors your required visa type
     • Has or is affiliated with a cardiothoracic surgery service
2. Preliminary Surgery spots
   • Highly common in SOAP.
   • Especially valuable if:
     • Program has a cardiothoracic or advanced surgical program (vascular, transplant, etc.)
     • Program has a track record of converting prelims to categorical positions or supporting strong fellowship matches.
3. Transitional Year and Internal Medicine
   • Prioritize programs with:
     • Strong ICU and procedural exposure
     • Robust cardiology, cardiac ICU, or cardiothoracic surgery departments
   • Emphasize in your application how this year will strengthen your readiness for surgical or cardiothoracic training.

4.2 Application Volume and Prioritization

In SOAP, you have a limited number of applications per round (historically 45 total applications across rounds). This can change, so verify the current year’s limits.

Strategy for an IMG pursuing heart surgery training:

• First pass (Round 1):
  • Emphasize General Surgery categorical and Preliminary Surgery positions.
  • Include Transitional Year programs that list strong perioperative/ICU curricula.
• Second pass:
  • Expand to Internal Medicine and other prelim positions that keep you clinically active and in the U.S. system.

Avoid using all your applications on only the most competitive or least IMG-friendly positions. Balance ambition with practicality.

4.3 Tailoring Your Personal Statement and Application

SOAP preparation includes having tailored personal statements ready to deploy:

• For General Surgery categorical (with CT goal)
  • Highlight:
    • Consistent surgical interests throughout medical school
    • Exposure to cardiothoracic surgery (observerships, electives, research)
    • Long-term goal: cardiothoracic fellowship after robust general surgery training
  • Emphasize:
    • Operative endurance, resilience, teamwork, and attention to detail
• For Preliminary Surgery
  • Emphasize:
    • Dedication to surgical training even when the path is not guaranteed
    • Willingness to work hard, take call, and support the team
    • Clear plan: use prelim year to strengthen your competitiveness for categorical surgery
  • Avoid sounding like you treat the prelim year as “only a backup”; instead, frame it as a committed first step.
• For Transitional Year/Internal Medicine
  • Connect your interest to cardiothoracic-adjacent domains:
    • Critical care, hemodynamics, complex cardiac pathology
    • Strong foundation in medical management of cardiac patients
  • Clearly state:
    • You value a broad, strong clinical base that will support future advanced procedural/surgical training.

Reassign letters in ERAS logically:

• Surgery-focused applications → prioritize letters from surgeons
• Medicine-focused applications → include at least one strong internal medicine or ICU/anesthesia letter where possible

---

Step 5: Communication, Interviews, and Professionalism During SOAP

SOAP offers are often preceded by brief, high-yield interactions with programs—sometimes only 10–20 minutes long.

5.1 Preparing for Rapid Interviews

Common questions for an IMG with a surgical/CT interest:

• “Tell me about yourself and your interest in our specialty.”
• “Why surgery (or this transitional year/IM position) if your long-term goal is cardiothoracic?”
• “Why did you go unmatched, and what have you learned from the process?”
• “How will you handle the workload and stress of a busy surgical service?”
• “Where do you see yourself in 5–10 years?”

SOAP preparation should include:

• A 2–3 sentence introduction clearly stating:
  • Your medical school background and IMG status
  • Your surgical/Cardiothoracic interest
  • A unique asset (research, language skills, work in resource-limited settings, etc.)
• A concise explanation for being unmatched, focusing on:
  • Systemic or strategic factors (e.g., too few programs ranked, over-concentration in highly competitive I-6 CT programs)
  • Growth since initial application (research, clinical work, improved language skills)

5.2 Explaining Your Cardiothoracic Ambitions Without Alienating Non-CT Programs

Programs may worry that you will be “too focused” on CT and not committed to their specialty.

Reframe your interest:

• For General Surgery programs:
  • “I see CT surgery as a natural evolution from a strong foundation in general surgery. My immediate goal is to be the best general surgery resident I can be, so I can care for complex patients and contribute meaningfully to the team.”
• For Prelim Surgery:
  • “I know that prelim positions can be uncertain, but I’m fully committed to contributing at the level of a categorical resident. I want to earn strong evaluations and letters while helping your program care for surgical patients.”
• For Transitional Year/IM programs:
  • “Even if I ultimately pursue surgical training, I know that understanding the medical side of cardiac disease, intensive care, and perioperative optimization is essential. I am committed to fully embracing this year’s curriculum.”

5.3 Professional Conduct and Follow-Up

• Respond to emails and calls promptly—have your phone fully charged and near you.
• Keep time zones in mind, especially if you are living outside the U.S.
• After brief interview calls, a short, professional thank-you email can reinforce your interest, but do not violate NRMP communication rules by asking for ranking promises or offers.

---

Step 6: Emotional Resilience and Post-SOAP Planning

The SOAP residency period is emotionally intense. As an IMG with a high-aspiration field like cardiothoracic surgery, the pressure can be even greater.

6.1 Managing Stress During SOAP

• Create a structured schedule for Match Week:
  • Time blocks for reviewing unfilled positions
  • Time slots for potential interviews
  • Short breaks to eat, rest, and hydrate
• Designate a support person (mentor, friend, family) who:
  • Understands what SOAP is
  • Can help you process decisions without escalating anxiety
• Avoid comparing yourself in real time with peers on social media or online forums. Focus on your path and decisions.

6.2 If You Match Through SOAP

If you secure a position:

• Accept with gratitude and professionalism—this is your starting platform.
• If your position is not in general or cardiothoracic surgery:
  • Map out how this year will build competencies relevant to future cardiothoracic training:
    • Master hemodynamics, ventilator management, perioperative cardiology
    • Seek rotations in cardiac ICU, CT surgery services (if available)
• During your residency year:
  • Build relationships with mentors in surgery, cardiology, or ICU
  • Maintain an updated CV and engage in CT-relevant projects when possible

6.3 If You Do Not Match Even After SOAP

This outcome is painful but far from the end of your path.

For an IMG aspiring to cardiothoracic surgery, consider:

• Structured research positions in cardiothoracic surgery or cardiac sciences:
  • Many university CT surgery departments offer 1–2 year research fellowships
  • These can provide:
    • Publications, presentations, and U.S. references
    • Exposure to CT surgeons who may advocate for you later
• Additional U.S. clinical experience (USCE):
  • Hands-on externships, sub-internships (if you are early after graduation)
  • Observerships in strong CT or surgical centers
• Exam or skill strengthening:
  • If your Step 2 CK is borderline, consider retaking if eligible, or strengthen other aspects like OET, communication courses, and simulation training.
• Improved application strategy for next cycle:
  • Broaden your specialty and program list
  • Apply earlier and more widely to general surgery and related fields

Reframe your journey as a multi-step pathway toward heart surgery training rather than a single all-or-nothing event.

---

Frequently Asked Questions (FAQ)

1. Is it realistic for an IMG to get a cardiothoracic surgery residency directly through SOAP?

Direct entry into cardiothoracic surgery residency (especially integrated I-6 programs) is extremely rare for any applicant, and especially for IMGs. These programs are few and intensely competitive; they almost never appear on the SOAP unfilled list. Your SOAP residency strategy should focus first on general surgery categorical or preliminary surgery positions that can lead to cardiothoracic training later, rather than aiming for a direct CT position via SOAP.

2. How can a preliminary surgery position obtained through SOAP still help my cardiothoracic surgery goal?

A prelim surgery year can be a powerful stepping stone if you:

• Work hard and gain strong clinical evaluations
• Build mentoring relationships with general and cardiothoracic surgeons
• Seek involvement in cardiothoracic cases, ICU care, and related research
• Use your prelim year to re-apply for:
  • Categorical general surgery
  • Occasionally, advanced positions in high-demand surgical fields

Programs often value prelim residents who prove themselves capable and reliable; some may offer categorical positions when spots open, or provide strong recommendations for your next application cycle.

3. As an IMG, should I apply to internal medicine or transitional year positions during SOAP if my ultimate goal is cardiothoracic surgery?

Yes, as long as you approach them strategically. Transitional Year and Internal Medicine positions:

• Keep you clinically active in the U.S. system
• Offer exposure to cardiology, cardiac ICU, and perioperative medicine
• Allow you to develop critical skills (communication, complex patient management, EHR familiarity)

These positions can strengthen your profile and maintain momentum while you plan a future re-application to surgical pathways. In your SOAP preparation and interviews, emphasize how this training will make you a more capable future surgical or cardiothoracic trainee.

4. What is SOAP preparation I should start at least 3–6 months before Match Week as an IMG interested in cardiothoracic surgery?

At least 3–6 months before Match Week, you should:

• Confirm NRMP and ECFMG eligibility and track visa/ECFMG timelines
• Build a surgery-oriented ERAS profile with:
  • Updated experiences highlighting surgery, ICU, and cardiothoracic exposure
  • Multiple pre-written personal statements tailored to:
    • General Surgery
    • Preliminary Surgery
    • Transitional Year/Internal Medicine
• Secure strong LoRs from:
  • U.S. surgeons (including CT if possible)
  • ICU/anesthesia/cardiology mentors where relevant
• Research SOAP-friendly specialties and program types, with notes on:
  • IMG friendliness
  • Visa sponsorship
  • Presence of cardiothoracic services
• Practice short, focused interview answers that explain:
  • Why you went unmatched
  • Why you are still committed and prepared
  • How non-CT positions will support your long-term CT goal

This proactive SOAP preparation ensures you can respond decisively and strategically if you find yourself in SOAP, keeping your long-term cardiothoracic surgery aspirations alive.