Essential SOAP Preparation Guide for MD Graduates in Emergency Medicine

Understanding SOAP for an MD Graduate in Emergency Medicine

For an MD graduate aiming for an emergency medicine residency, the Supplemental Offer and Acceptance Program (SOAP) can feel like a high‑pressure, last‑minute scramble. In reality, the most successful applicants treat SOAP like a parallel match process that demands the same level of planning and strategy as the regular allopathic medical school match.

If you’re targeting an emergency medicine residency and are worried you might need to participate in SOAP—or you already know you will—your preparation should start well before Match Week. This guide walks you through what SOAP is, how it works, and specifically how an MD graduate in Emergency Medicine should prepare to maximize the odds of securing a solid position.

We’ll cover:

• The structure and rules of SOAP
• EM‑specific realities in the SOAP environment
• Step‑by‑step SOAP preparation before Match Week
• Application, communication, and ranking strategies
• Common pitfalls and how to avoid them

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What Is SOAP and How Does It Work?

SOAP in a Nutshell

SOAP (Supplemental Offer and Acceptance Program) is the NRMP‑managed process that allows unmatched or partially matched applicants to obtain unfilled residency positions during Match Week. It is not a free‑for‑all: it is scheduled, rule‑bound, and heavily structured.

Understanding what is SOAP is critical:

• Who participates?

  • Unmatched applicants who are SOAP‑eligible (as confirmed in NRMP’s system)
  • Applicants who are partially matched (e.g., matched to a preliminary year but not advanced position)
  • Programs with unfilled positions after the main rank list processing

• Where does it happen?

  • Through ERAS (for applications and document transmission)
  • Through NRMP (for offers and acceptances)

• What you can do:

  • Apply to up to 45 programs total during SOAP
  • Receive offers in rounds throughout Match Week
  • Accept only one offer at a time (accepting an offer ends your SOAP participation)

For an MD graduate residency applicant in Emergency Medicine, SOAP may involve:

• Traditional categorical EM positions that went unfilled
• Combined programs (e.g., EM‑IM) with vacancies
• Transitional year or preliminary spots as strategic alternatives if categorical EM positions are limited

Key SOAP Rules You Must Know

Before crafting an EM SOAP strategy, be absolutely clear on the ground rules:

• No outside solicitation:
  During SOAP, you cannot initiate contact with programs outside of ERAS/NRMP rules. Programs may contact you, but cold‑calling or emailing to request consideration is prohibited.

• Application limit:
  Maximum of 45 total SOAP applications—not per round, but across all rounds combined.

• Offer rounds and timing:
  NRMP releases a list of unfilled programs and conducts multiple offer rounds. In each round:

  • Programs submit preference lists of eligible applicants.
  • NRMP extends offers electronically.
  • You have a limited window (typically a few hours) to accept or reject an offer.

• Binding acceptance:
  Once you accept an offer, it is binding just like the main Match. You exit SOAP and cannot seek another residency position through NRMP in that cycle.

Understanding these mechanics before Match Week is foundational SOAP preparation.

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The Emergency Medicine Landscape in SOAP

Why Emergency Medicine Is Unique in SOAP

Emergency Medicine (EM) has become increasingly competitive in recent years, with fluctuations in fill rates and applicant volumes. As an MD graduate seeking an emergency medicine residency, you must understand how EM behaves during SOAP:

• Volatility in unfilled positions:
  Some cycles see a notable number of EM positions entering SOAP; others see few. Many unfilled EM positions may be:

  • At newer or less well‑known programs
  • In geographically less popular regions
  • In community or hybrid academic‑community hospitals

• Program caution:
  EM program directors tend to be sensitive to fit and clinical readiness. In SOAP, they may:

  • Prioritize MD graduates with strong clerkship performance
  • Favor applicants who already demonstrated interest in EM in their original ERAS file (EM rotations, SLOEs, personal statement focused on EM)
  • Be cautious with candidates whose files suggest EM was initially a backup option

• SLOEs remain central:
  Standardized Letters of Evaluation (SLOEs) are still critically important in EM. During SOAP, programs may quickly skim:

  • Number and quality of EM SLOEs
  • Comments on clinical performance, teamwork, and communication
  • Any red flags or concerns labeled as “below expected,” “needs supervision,” or professionalism issues

When EM SOAP Is Realistic vs. When to Pivot

You must be clear‑eyed about your competitiveness:

More favorable EM SOAP prospects if:

• You have 2–3 strong EM SLOEs from reputable sites
• You performed well on EM rotations (Honors/High Pass with strong narrative comments)
• You had reasonable Step scores and no major professionalism issues
• Your application already clearly centers around EM

Challenging EM SOAP prospects if:

• You have 0–1 EM SLOEs, or they contain significant concerns
• You initially applied broadly to other specialties and only a few EM programs
• There are significant academic concerns (multiple failures, significant score gaps)
• You lack recent clinical experience (for older MD graduates)

In such cases, your SOAP preparation should include contingency planning:

• Applying to Transitional Year (TY) or Preliminary Medicine/Surgery positions in SOAP
• Strategically planning a re‑application to EM next cycle with additional clinical work, research, or another degree year

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Pre–Match Week SOAP Preparation: What to Do Before You Need It

The most successful SOAP outcomes happen when applicants prepare months ahead, not on Monday afternoon of Match Week. For an MD graduate in EM, your SOAP preparation should fall into several buckets: documents, strategy, and mindset.

1. Optimize Your Core File Early

Whether or not you end up in SOAP, your EM application should be as strong as possible:

• Emergency Medicine Personal Statement

  • Primary PS: Focused on your genuine reasons for EM: acuity, teamwork, shift work, patient diversity, and your specific attributes (calm under pressure, communication, adaptability).
  • SOAP‑Ready PS: Save a modified version on your computer that:
    • Is slightly more general (in case you pivot to TY or prelim spots)
    • Highlights broad strengths: work ethic, clinical reliability, teamwork, adaptability

• SLOEs and Letters of Recommendation

  • Aim for 2–3 EM SLOEs from different types of settings if possible (academic, community).
  • Have at least one non‑EM letter (e.g., Internal Medicine, Surgery) that:
    • Praises your reliability, professionalism, and general clinical skills
    • Can support SOAP applications to non‑EM positions if needed

• CV and Experiences Section

  • Make sure your ERAS entries:
    • Clearly document EM‑relevant activities: ED research, EMS involvement, ultrasound, leadership roles.
    • Show consistent professionalism and no large unexplained gaps.

2. Build a SOAP Strategy Document

Before Match Week, create a SOAP Strategy Document (Word or Google Doc) that you can rapidly adjust. Include:

• A Tiered Program List Template

  • Tier 1: EM programs you’d strongly consider in SOAP (geographic flexibility required)
  • Tier 2: Mixed EM plus TY/prelim programs
  • Tier 3: TY/prelim or other specialties you’d realistically accept if needed

• Pre‑written Email Templates (for after SOAP)
  While you cannot solicit programs during SOAP, you might contact them afterward if positions are still open or for future cycles. Draft:

  • A template for expressing interest in future EM openings
  • A template for requesting feedback if you go unmatched

• Personal Decision Rules
  Clarify in writing:

  • Are you willing to accept any EM spot anywhere, regardless of geography, if the environment is safe and accredited?
  • Would you prefer a strong TY/prelim in a good institution over a marginal EM program with significant concerns?
  • Are you prepared to take a gap year and strengthen your EM application if necessary?

Having these rules decided in advance prevents panic‑driven decisions when SOAP offers appear.

3. Understand SOAP Logistics and Practice Scenarios

• Review NRMP and ERAS SOAP guides each year.
• Know the exact timing of:
  • Unmatched notification
  • List of unfilled programs release
  • Each SOAP application and offer round
• Practice with hypothetical scenarios:
  • “If I get an EM offer in a less‑desired region in Round 1, do I accept, or hold out hoping for a closer program in Round 2?”
  • “If only TY/prelim options appear by Round 3, what’s my threshold to accept vs. wait?”

This prework helps you act decisively and rationally under time pressure.

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Executing SOAP During Match Week: Step‑by‑Step for EM Applicants

Once Match Week begins and you learn you are unmatched or partially matched, move systematically. For an MD graduate residency applicant in EM, your goal is to quickly identify realistic EM positions while keeping contingencies open.

Step 1: Emotional Reset and Rapid Assessment

When you see “You are unmatched” (or partially matched), there’s an understandable emotional impact. Take 30–60 minutes to:

• Breathe and acknowledge disappointment.
• Reach out briefly to a trusted mentor, EM advisor, or dean.
• Remind yourself: SOAP is still part of the Match, and many solid physicians got their start here.

Then shift into action mode.

Step 2: Analyze the List of Unfilled Programs

When NRMP releases the list of unfilled programs:

1. Filter for Emergency Medicine

   • Identify categorical EM and EM‑combined (e.g., EM‑IM) programs first.
   • Note their location, accreditation status, and type (academic vs community).

2. Assess Competitiveness vs. Your Application

   • Prioritize programs where you:
     • Meet or exceed their usual Step/COMLEX expectations (if known).
     • Have some geographic or mission fit (e.g., similar patient population, prior experiences in that region).
     • Can credibly appear enthusiastic and aligned with their mission.

3. Identify Non‑EM Backup Categories

   • Transitional Year (often at large academic centers or community teaching hospitals).
   • Preliminary Medicine or Surgery (with active EM departments where you might build connections).
   • A small number of non‑EM categorical programs only if they align with your genuine long‑term flexibility.

Step 3: Construct Your SOAP Application List (Up to 45 Programs)

A strategic EM SOAP list might look like:

• 15–20 EM programs

  • All categorical EM in SOAP that you would realistically consider
  • EM‑IM hybrid programs if they match your background and interests

• 10–15 TY programs

  • Preferably at hospitals with strong EM departments where you can later rotate and build relationships

• 10–15 Preliminary IM/Surgery programs

  • Again prioritizing sites with busy EDs and opportunities to demonstrate value to EM faculty

Adjust numbers based on how many EM positions are actually available that year. In a year with many unfilled EM positions, you can lean heavier into EM; in a tight year, diversify earlier.

Step 4: Tailor Personal Statements and Program Signals

During SOAP you can submit different personal statements to different programs. Use this strategically:

• For EM Programs:

  • Use a PS that clearly states EM as your enduring goal.
  • Emphasize:
    • Your resilience and ability to thrive in high‑acuity settings
    • Team‑based communication
    • Specific EM experiences and mentors who shaped you
    • Willingness to embrace the program’s patient population and location

• For TY/Prelim Programs:

  • Emphasize broad clinical strengths, work ethic, and adaptability.
  • Briefly mention your interest in EM but frame it as a long‑term professional direction, not a short‑term transactional plan.

Avoid stating in a TY/prelim PS that you only plan to be there one year and then leave; instead, focus on your commitment to fully engage and contribute during the year.

Step 5: Be Ready for Program Outreach and Quick Interviews

During SOAP, some EM programs (and many TY/prelim programs) will:

• Email or call to:
  • Clarify your interest in the program/location
  • Ask about specific aspects of your application (gaps, failures, SLOE comments)
  • Conduct brief, focused interviews (sometimes same day)

Preparation tips:

• Have a 1–2 minute EM‑focused elevator pitch:

  • Why EM and how your experiences have confirmed this choice
  • What strengths you bring to an ED team
  • Why you would thrive in their program’s environment

• Prepare concise answers for potential red flags:

  • Test failures: own them, describe growth, provide evidence of improvement.
  • Gaps: explain constructively and reassure readiness for full‑time residency.
  • Limited EM exposure: highlight related acute‑care or ED‑adjacent experience.

• Demonstrate geographic and institutional flexibility honestly:

  • If you’re truly willing to train in their region, say so clearly.
  • If there are genuine constraints (family, visa issues), communicate them succinctly and early.

Step 6: Navigating Offer Rounds and Decisions

When offers begin:

1. Review offers against your pre‑written decision rules.

   • Does this EM program meet your baseline standards for training quality, safety, and accreditation?
   • Is it realistically livable for you and anyone who depends on you?

2. If you receive an EM offer in Round 1 that meets your minimum bar:

   • For many EM‑focused MD graduates, the default is to accept a solid EM offer in Round 1 rather than gambling on later rounds.
   • Exceptions:
     • You have multiple EM offers and a clear preference.
     • You have significant reason to believe a much‑preferred EM program will likely offer you in a subsequent round (rare and speculative).

3. If only TY/prelim offers appear initially:

   • Compare them against your long‑term strategy:
     • Is this a strong institution where a year of solid performance could help you re‑enter the allopathic medical school match for EM?
     • Are you willing to risk going fully unmatched this cycle for the possibility of a different TY/prelim spot later in the week?

4. Once you accept:

   • Your SOAP journey ends.
   • Begin mentally transitioning into preparing for residency and planning a path forward within or toward EM, depending on what you matched into.

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After SOAP: Planning Your Emergency Medicine Career Trajectory

Whether you match into an emergency medicine residency through SOAP, secure a TY/prelim spot, or remain unmatched, your EM ambitions are still viable—but your path may differ.

If You Match into an EM Residency via SOAP

• Embrace your program fully.

  • Do not treat it as a placeholder; EM is small, and reputations travel.
  • Invest in relationships with faculty and peers from day one.

• Address any weaknesses that contributed to SOAP.

  • If your test scores or certain rotations were weaker, seek early mentorship and remediation opportunities.
  • Demonstrate you are a motivated, coachable resident.

• Resist comparison.

  • Your entry route (main Match vs EM match SOAP) becomes irrelevant if you perform well in residency.

If You Match into TY or Prelim IM/Surgery

You now have an important year to strengthen your EM candidacy for the next allopathic medical school match:

• Excel clinically.

  • Be the intern that EM faculty and hospitalists want on their team.
  • Ask for ED rotations if not automatically part of your schedule.

• Pursue EM‑related projects.

  • Get involved in ED research, QI, ultrasound, or EMS projects.
  • Seek letters from EM faculty who can comment on your work ethic and growth.

• Rebuild your EM application strategically.

  • Update your personal statement with new experiences.
  • Add new letters (ideally, at least one SLOE‑style letter from EM faculty who observed you as an intern).

If You Remain Unmatched After SOAP

This is difficult, but not career‑ending. With support and planning, many physicians re‑enter the EM match or pivot to related fields.

• Obtain structured clinical experience.

  • Research fellowships, non‑ACGME clinical fellowships, or academic positions with ED involvement.
  • Avoid long stretches without clinical activity if you hope to re‑apply.

• Seek candid feedback.

  • From EM program directors, advisors, or deans.
  • Ask: “What specific changes over the next 12–18 months would most improve my EM competitiveness?”

• Decide on primary and secondary plans.

  • Primary: targeted EM re‑application with improved SLOEs, experiences, and test performance if needed.
  • Secondary: other acute‑care specialties (e.g., critical care via an IM route, hospital medicine, anesthesia, etc.) if EM proves persistently out of reach.

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Frequently Asked Questions (FAQ)

1. How should an MD graduate in EM balance EM programs vs. TY/prelim positions in SOAP?

Balance depends on how many emergency medicine residency positions are in SOAP and your competitiveness:

• If there are numerous EM SOAP positions and you have solid EM SLOEs and performance, you can:

  • Dedicate most of your 45 applications to EM programs.
  • Reserve 10–15 spots for strong TY/prelim options as a safety net.

• If there are few EM positions or your EM application is relatively weaker:

  • Apply to all feasible EM programs in SOAP.
  • Intentionally include a larger number of TY/prelim positions early rather than waiting until the final round.

2. Does participating in SOAP hurt my chances in future EM match cycles?

Simply participating in SOAP does not inherently harm you. Factors that may affect future cycles include:

• Program‑specific impressions:
  If a program saw your application in SOAP and declined, they may or may not reconsider you later depending on your subsequent growth.

• Narrative and improvement:
  If, after SOAP, you:

  • Gain strong clinical experiences
  • Obtain powerful, updated SLOEs
  • Display clear improvement in any weak areas

then many EM programs will view your re‑application positively, often as evidence of resilience and determination.

3. Should I contact programs directly during SOAP to express interest?

No. NRMP rules are strict: applicants may not initiate contact with programs during SOAP to solicit or promote their candidacy. Programs may contact you, and you can respond, but you should not:

• Cold email program directors asking for interviews during SOAP
• Call program coordinators to ask them to review your file

Violating this can reflect poorly on you and potentially jeopardize your participation. Save direct outreach for after SOAP concludes and only if done professionally.

4. Is it better to accept a less‑desired EM program in SOAP or a strong TY year and re‑apply?

There is no single right answer; it depends on your values and circumstances:

• Accepting a less‑desired EM program:

  • Pros: You’re training directly in your chosen specialty; no need to re‑apply.
  • Cons: If the program has significant structural issues (limited case mix, poor support, accreditation concerns), your overall training experience may be affected.

• Accepting a strong TY and re‑applying:

  • Pros: Opportunity to strengthen your application at a reputable institution; potentially position yourself for a more competitive EM program next cycle.
  • Cons: Uncertainty—re‑matching is not guaranteed; additional financial and emotional cost of another application cycle.

Your SOAP preparation should include a personal decision framework, ideally developed with mentors who know both you and the EM landscape well.

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By understanding the mechanics of SOAP, the peculiarities of the emergency medicine residency market, and your own priorities as an MD graduate, you can approach SOAP not as a desperate last resort, but as a structured, strategic opportunity. With thoughtful preparation, clear decision rules, and honest assessment of your strengths and gaps, you can significantly improve your chances of emerging from Match Week with a path that moves you meaningfully toward a career in Emergency Medicine.