Mastering SOAP Preparation for Your Internal Medicine Residency Match

Understanding SOAP in the Context of Internal Medicine

The Supplemental Offer and Acceptance Program (SOAP) has become an essential part of the residency match landscape, especially in competitive fields like internal medicine. For many applicants, the IM match is high stakes: it is a gateway not only to core internal medicine training but also to highly sought-after subspecialty fellowships.

To prepare effectively, you must first clearly understand: what is SOAP, how it works, and how it uniquely impacts applicants targeting internal medicine residency.

What Is SOAP?

SOAP is a structured, time-limited process run by the NRMP during Match Week to help eligible unmatched or partially matched applicants secure unfilled, NRMP-participating residency positions.

Key features:

• Takes place during Match Week (Monday–Thursday) before the main Match Day on Friday.
• Only open to ERAS applicants who are unmatched or partially matched and certified as SOAP-eligible by NRMP.
• Applicants apply only to programs with unfilled positions listed in NRMP’s R3 system.
• Communications with programs are tightly regulated (no unsolicited calls/emails outside allowed periods).
• Offers occur in multiple “Rounds" where programs extend offers and applicants can accept or reject in real time.

SOAP is not a free-for-all scramble like the pre-2012 “Scramble.” It is organized, rules-based, and requires serious advance planning—especially if you are targeting internal medicine residency positions, which often represent a large share of unfilled slots but also attract many applicants in SOAP.

Why SOAP Preparation Matters for Internal Medicine Applicants

Internal medicine is both:

• A core categorical specialty many U.S. graduates purposefully pursue, and
• A major “safety” field for applicants from other specialties, along with many IMGs and reapplicants.

As a result:

• Internal medicine programs typically have more SOAP positions than many specialties.
• Competition is still significant, and programs differ widely in academic rigor, fellowship pipelines, and support resources.
• Well-prepared candidates can strategically target programs that best fit their long-term goals, rather than just “any IM position.”

Effective SOAP preparation must start before Match Week—ideally several months ahead—and should be integrated into your overall IM match strategy, whether you ultimately match in the main algorithm or through SOAP.

---

Pre–Match Week SOAP Preparation: Set Yourself Up Early

The biggest mistake applicants make is assuming they’ll match and doing no SOAP preparation at all. Smart applicants prepare quietly and calmly, hoping never to need it, but ready if they do.

Step 1: Understand Your Risk of Entering SOAP

Several months before rank list certification, realistically assess your risk. You don’t need to panic, but you do need a clear view.

Risk indicators for potentially entering SOAP for internal medicine residency:

• USMLE/COMLEX scores:
  • Step 1 pass only (no numeric score) + borderline Step 2.
  • One or more failures or multiple attempts.
• Limited interviews:
  • For categorical IM, <8–10 interviews (U.S. MD/DO) may increase risk.
  • For IMGs, risk increases significantly with <10–12 interviews, depending on profile.
• Red flags:
  • Remediated courses, professionalism issues, LOA for non-health reasons, prior dismissal.
• IMG-specific factors:
  • Older YOG (year of graduation).
  • Limited or no U.S. clinical experience in internal medicine.
• Overly aggressive rank list:
  • Ranking only highly competitive university IM programs, or very short rank list.

If you have any of these risk factors, build a SOAP contingency plan early. This is not pessimism; it is a professional risk-management strategy.

Step 2: Ensure SOAP Eligibility and Documentation

To participate in SOAP:

1. Register for the NRMP Match and pay fees by the deadline.
2. Register and apply via ERAS to residency programs.
3. Ensure USMLE/COMLEX scores, transcripts, and MSPE are uploaded in ERAS.
4. Be fully unmatched or partially matched at the start of Match Week.
5. Be certified as SOAP-eligible in NRMP’s R3 system.

Preparation tips:

• Confirm all your exam results are in ERAS at least 1–2 months before Match Week.
• Verify ECFMG certification timeline if you are an IMG; delays can affect eligibility.
• Keep copies of your CV, personal statement, and letters of recommendation organized and ready to repurpose quickly.

Step 3: Create SOAP-Specific Internal Medicine Materials in Advance

You do not want to start writing from scratch on Monday of Match Week. Prepare SOAP-tailored versions of key documents well beforehand.

1. SOAP-Focused Internal Medicine Personal Statement

Prepare a shorter, sharper, SOAP-specific IM personal statement, distinct from your main application:

• Length: 4–5 paragraphs, ~500–650 words.
• Focus:
  • Clear commitment to internal medicine (not “backup” language).
  • Concrete patient-care experiences reflecting IM thinking (complex cases, diagnostic reasoning, longitudinal care).
  • Evidence of resilience, professionalism, and team-based care.
  • Why you would be a reliable, low-maintenance intern.

Avoid:

• Long “origin stories” at the expense of practical readiness.
• Mentioning prior plans to match into another specialty in a way that diminishes your IM commitment. If you are a switcher, frame it as a thoughtful, purposeful transition.

2. Multiple IM Letters Available in ERAS

For SOAP, you cannot import new letters quickly, but you can reassign different existing letters:

• Aim for at least 3 strong IM-specific letters in ERAS:
  • From IM attendings who supervised you directly.
  • From IM subspecialists (cards, GI, ID, etc.) with meaningful clinical contact.
  • A department chair or program director letter if available.
• Keep a mix of academic and community IM letters if possible; SOAP programs are diverse in type.

3. A SOAP-Oriented CV and Talking Points

While ERAS automatically provides your CV, create a condensed PDF version for your own use and for any allowed communications/post-SOAP outreach:

• One-page summary with:
  • Education and exams.
  • Core IM rotations and sub-internships with grades.
  • Research, QI, leadership, and teaching relevant to internal medicine.
• A separate document with key bullet-point talking points:
  • Top 3–4 IM strengths (e.g., “handles high patient volumes,” “strong EHR and documentation skills,” “comfortable presenting complex cases”).
  • 2–3 key patient-care stories that demonstrate your value.

---

Strategic Planning: Targeting the Right Internal Medicine Programs in SOAP

Knowing how SOAP works mechanically is important; knowing how to target the right programs is what actually gets you an internal medicine residency position you can thrive in.

Step 1: Understand the Landscape of IM SOAP Positions

Historically, internal medicine contributes a large number of unfilled positions each year—particularly in:

• Community-based hospitals
• Newly accredited programs
• Hospitals in rural or less-popular geographic regions
• Safety-net and high-service-burden institutions

However, the quality and training experience across these programs is highly variable. Your SOAP preparation should include a plan to screen programs quickly and consistently.

Step 2: Build a Prioritized Program Profile Framework

Before Match Week, outline what matters most to you. For SOAP, you must balance urgency with long-term training quality.

Key attributes to consider:

1. Accreditation and stability

   • ACGME accreditation status.
   • Longevity of the program (brand-new vs. established).
   • Evidence of stable leadership (PD tenure, no recent major disruptions).

2. Training environment

   • Patient volume and case mix (safety-net vs. suburban community).
   • ICU exposure and procedure opportunities.
   • Presence of subspecialty services and fellowships.

3. Fellowship and career outcomes

   • Track record of graduates entering fellowships (even if mostly regional).
   • Hospital’s reputation within its region.

4. Support for IMGs and diverse backgrounds

   • Percentage of current residents who are IMGs/DOs.
   • Visa sponsorship practices (if relevant).

5. Personal factors

   • Geography, cost of living, social support.
   • Wellness culture and resident satisfaction (to the extent you can infer).

Create a simple priority matrix (e.g., “must have,” “strongly prefer,” “nice to have”) that you can apply quickly to SOAP-available programs when the list is released.

Step 3: Pre-Identify Potential SOAP “Zones”

You cannot see the official unfilled list before Monday of Match Week, but you can anticipate likely types of programs and regions:

• Regions more likely to have unfilled IM positions:
  • Rural Midwest and South
  • Less densely populated areas of the Northeast or West
• Program types:
  • Community-based without university affiliation
  • Newly expanded programs
  • Hospitals in medically underserved regions

You don’t need to guess exact programs, but you can discuss with mentors:

• “If I needed to SOAP, would I be okay with a community IM program in State X or Y?”
• “How do you see fellowship prospects from smaller programs versus large academic centers?”

This pre-thinking allows you to move faster without emotional paralysis when you see the actual SOAP list.

---

Executing SOAP Week for Internal Medicine: A Day-by-Day Guide

When Monday of Match Week arrives and you learn you are unmatched or partially matched, you will have intense emotions and very little time. Having a pre-written plan is essential.

Monday: Confirmation, List Review, and Application Strategy

Step 1: Process the Result Quickly but Constructively

You will learn from NRMP whether you are:

• Fully matched
• Partially matched (e.g., advanced position only, no preliminary)
• Unmatched

If you are SOAP-eligible, focus your energy on action, not self-criticism. Many physicians you admire have used SOAP or prior Scramble to secure their positions.

Step 2: Review the Unfilled Positions List in R3

Once NRMP releases the list:

• Filter by Specialty: Internal Medicine (Categorical vs. Preliminary).
• Apply your pre-built priority framework:
  • Exclude programs that truly do not fit (e.g., no visa sponsorship if you need it).
  • Flag higher-priority programs (e.g., more established, better location for you).

You may apply to up to 45 programs total during SOAP across all specialties. For applicants whose primary goal is internal medicine residency, it is usually wise to dedicate most or all of these to IM unless you have a clear, realistic parallel path (e.g., transitional year with an advanced position already secured).

Step 3: Customize Your Application Materials

Within ERAS:

• Assign your SOAP-specific IM personal statement for all internal medicine programs.
• Tailor if time permits:
  • For community or rural programs: emphasize adaptability, service to underserved populations, and interest in broad general IM.
  • For academic-leaning community programs: highlight research/teaching experience and interest in academic internal medicine.
• Reassign letters of recommendation:
  • Use your strongest IM letters universally.
  • Consider slightly different combinations if you know specific program characteristics (e.g., if a program is strong in cardiology and you have a cardiology letter).

Aim to submit applications as early as possible Monday, to maximize review time by programs.

Tuesday–Thursday: Interviewing and Rounds of Offers

Interviews During SOAP

Programs may conduct brief, high-yield interviews via:

• Phone
• Zoom/MS Teams
• Occasionally in-person if local, though virtual is far more common.

Expect shorter, more focused conversations (10–25 minutes). Prepare:

• A 2–3 minute summary of who you are and why internal medicine.
• Clear explanations for:
  • Any gaps, red flags, or career changes.
  • Why you didn’t match earlier and what you learned from the process.
• 2–3 strong patient-case stories demonstrating:
  • Clinical reasoning.
  • Ownership of patient care.
  • Collaboration and communication with multidisciplinary teams.

Common SOAP IM interview questions:

• “Why internal medicine, and why now?”
• “What have you been doing since graduation?” (for older YOG/IMGs)
• “Tell me about a challenging patient case and what you learned.”
• “How do you handle high workload and stress?”
• “If you have multiple offers, what will matter most in your decision?”

Keep notes after each interaction:

• Program culture and vibe.
• PD/APD’s expectations and communication style.
• Your overall comfort level and interest.

Understanding SOAP Rounds and Offers

SOAP typically has multiple rounds (e.g., four):

• Programs submit lists of preferred applicants.
• NRMP releases offers to selected candidates at specific times.
• You can:
  • Accept (binding; you exit SOAP for that specialty/position).
  • Reject (permanent; you cannot get another offer from that program).
  • Let expire (also counts as rejection).

Internal medicine strategy:

• Rank-order in your own mind which SOAP programs you would accept immediately if offered.
• For lower-priority programs, decide:
  • Would you accept in an early round if it’s your only offer?
  • Would you gamble on later rounds for a potentially better fit?

Remember: any ACGME-accredited IM residency that will train and support you is infinitely better than remaining unmatched. However, that does not mean you must accept the very first offer if it severely compromises key needs (e.g., unsafe environment, absolutely incompatible geography, no visa option when you need one).

---

Optimizing Your Candidacy for IM SOAP: Practical Improvements and Messaging

Even with limited time, there are ways to present yourself as a uniquely strong internal medicine applicant during SOAP.

Highlight Experiences That Matter to Internal Medicine PDs

Last-minute interview prep should focus on IM-relevant competencies:

1. Clinical reasoning and ownership

   • Be ready to describe:
     • Presenting new admissions.
     • Following complex inpatients over several days.
     • Leading or meaningfully contributing to daily rounds.

2. System-based practice

   • Examples of:
     • Coordinating care between consultants, nurses, and therapists.
     • Following up test results and ensuring safe discharges.

3. Professionalism and reliability

   • Stories demonstrating:
     • Taking extra responsibility willingly.
     • Owning and learning from mistakes.
     • Being dependable during nights/weekends/holidays.

4. Communication skills

   • Breaking bad news with support.
   • Explaining complex chronic diseases in accessible terms.

Addressing Red Flags and Non-Match Outcomes

Programs know SOAP applicants have had setbacks. What they look for is growth and insight.

Common situations and how to frame them:

• Failed an exam (Step 1/2/CK):

  • Own it without excuses.
  • Explain concrete changes in study methods, time management, and resource use.
  • Emphasize subsequent improvement or consistency in performance.

• Switched from another specialty:

  • Articulate a clear, positive rationale for internal medicine.
  • Avoid framing IM as merely “more available.”
  • Highlight experiences that confirmed IM is the right long-term home for you.

• Older graduate or gap in training:

  • Describe clinical or related work you have done (research, scribe, observerships).
  • Emphasize that you remained clinically engaged and up to date.

Balancing Honesty and Strategy

You must remain truthful and within all NRMP ethics rules, but you can:

• Emphasize your genuine enthusiasm for each program you interview with.
• Tailor how you present your strengths to match program needs:
  • For high-volume community hospitals: reliability, resilience, and efficiency.
  • For academically inclined programs: scholarly curiosity, QI, and teaching.

---

Post-SOAP: Navigating Outcomes and Next Steps in Internal Medicine

Once SOAP concludes, you will be in one of three major scenarios. Each demands a thoughtful response.

Scenario 1: You Match into an Internal Medicine Position Through SOAP

If you accept a SOAP offer in internal medicine residency:

• Celebrate privately; you have secured an ACGME-accredited IM position.
• Email or message:
  • Program leadership with gratitude and enthusiasm.
  • Any mentors who supported you during SOAP.
• Begin logistical planning:
  • Visa processing (if needed).
  • Housing, relocation, onboarding paperwork, credentialing.

Also, set early expectations:

• Recognize that SOAP-entry residents can feel imposter syndrome.
• Remind yourself: PDs choose candidates in SOAP intentionally.
• Plan to meet or exceed expectations from Day 1 by:
  • Reviewing basic inpatient IM management (CHF, COPD, sepsis, DKA, etc.).
  • Arriving early, reading daily, and seeking feedback.

Scenario 2: You Match into a Non-IM Position but Still Aspire to IM

Some applicants may SOAP into preliminary medicine or another transitional/prelim year:

• Take the position seriously; many residents re-enter the IM match successfully after a strong prelim year.
• Build a track record of excellence:
  • Strong evaluations.
  • Solid PD/attending letters.
  • Involvement in QI projects or research.
• Stay connected to internal medicine PDs and mentors who can guide your future IM match.

Scenario 3: You Do Not Match Through SOAP

Not matching after SOAP is extraordinarily difficult emotionally, but it is not the end of an IM career.

Key immediate steps:

1. Stabilize emotionally and practically

   • Give yourself a short, defined time to grieve.
   • Reach out to a trusted mentor, dean, or advisor.

2. Clarify your IM goal

   • Are you committed to reapplying to internal medicine?
   • Are you open to other specialties or career paths?

3. Develop a 12–18 month remediation plan

   • Strengthen your application in targeted ways:
     • U.S. clinical experience in IM (observerships, externships, or research rotations).
     • Additional degrees or certificates (e.g., MPH, research fellowship) if strategically beneficial.
     • Targeted Step/COMLEX score improvement if exams are still pending (e.g., Step 3).
   • Rebuild with honest feedback from PDs and advisors who can review your prior application.

4. Avoid panicked, unstructured outreach

   • Post-SOAP, some unfilled positions may still be available outside NRMP. However:
     • Confirm that any offer does not violate NRMP policies.
     • Vet programs carefully for accreditation and training quality.

In all cases, keeping an open, growth-oriented mindset is crucial. Many excellent internists and subspecialists had non-linear paths to their IM residency.

---

Frequently Asked Questions About SOAP Preparation in Internal Medicine

1. How many internal medicine programs should I apply to during SOAP?

You can apply to up to 45 programs across all specialties. For applicants whose primary goal is internal medicine residency, it is usually reasonable to use the majority or all of those 45 applications on IM programs, unless:

• You are partially matched and need only a preliminary year, or
• You have a realistic alternative specialty you are equally committed to.

Your priority should be to maximize the number of reasonable IM programs that fit your basic needs (visa, location tolerance, accreditation).

2. Should my SOAP personal statement for internal medicine mention that I didn’t match?

You generally do not need to explicitly state that you didn’t match; it is understood in SOAP. Instead:

• Focus on your current readiness and commitment to internal medicine.
• If you must address it (e.g., obvious red flags), keep it brief and forward-looking, explaining what you learned and how you improved.

3. Can I contact internal medicine programs directly during SOAP?

Direct communication is strictly regulated:

• You may respond to contact initiated by programs (e.g., interview invitations).
• You must not cold-call or email programs outside the rules set by NRMP/ERAS.
• Violations can jeopardize your chances and may be considered unprofessional.

Always follow the most current NRMP and ERAS SOAP communication policies.

4. I’m an IMG targeting internal medicine. How is SOAP different for me?

For IMGs, SOAP can be both an opportunity and a challenge:

• Many internal medicine SOAP positions are open to IMGs, but:
  • Visa policies (H-1B vs. J-1 vs. no visa) vary widely.
  • Some community programs have no infrastructure for visa sponsorship.
• Preparation tips:
  • Confirm your ECFMG status and documentation early.
  • Pre-learn which states and regions are more IMG-friendly.
  • Ensure you have strong U.S. IM letters and experiences to highlight.

With focused SOAP preparation and a realistic strategy, IMGs can and do successfully enter internal medicine through SOAP each year.

---

Thoughtful, early SOAP preparation allows you to approach Match Week with less fear and more control, especially in a foundational specialty like internal medicine. By understanding the process, organizing your documents, and planning your IM strategy in advance, you significantly improve your chances of securing a residency position that will launch your career as an internist—whether it happens via the main IM match or through SOAP.