Essential SOAP Preparation Guide for Non-US Citizen IMGs in EM-IM Residency

Understanding SOAP for the Non-US Citizen IMG Targeting EM–IM

The Supplemental Offer and Acceptance Program (SOAP) is the organized process the NRMP uses to fill unfilled residency positions after the Main Match. For a non-US citizen IMG aiming at Emergency Medicine–Internal Medicine (EM–IM) combined programs, SOAP can be both a second chance and a significant challenge.

You must be ready before Monday of Match Week. By the time you find out you are unmatched or partially matched, there is almost no time left to build strategy or documents from scratch.

This guide focuses on SOAP preparation specifically for a non-US citizen IMG interested in EM–IM combined or related pathways (Emergency Medicine, Internal Medicine, and prelim/transitional options).

We will cover:

• What SOAP is (and what it isn’t) for foreign national medical graduates
• How the unique nature of EM–IM combined training affects your SOAP plan
• Concrete pre-SOAP preparation steps (documents, lists, strategy)
• How to think about visas, program selection, and flexibility as a non-US citizen IMG
• How to execute efficiently during the 4 intense SOAP days

Throughout, keep one mindset: SOAP is about readiness and realism. You prepare for the ideal outcome but design a safety net strong enough to keep your career moving if the ideal doesn’t materialize.

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1. What Is SOAP – And Why It Matters for EM–IM Non-US Citizen IMGs

1.1 Defining SOAP in Practical Terms

In simple terms, SOAP is:

• A four-day, tightly scheduled process during Match Week to fill unfilled residency positions
• Conducted via ERAS and NRMP, not by direct cold-calling programs
• Structured in rounds of offers, where you may receive multiple offers and must accept or reject in short time windows

If you are a non-US citizen IMG or foreign national medical graduate, SOAP is often your last opportunity in that application cycle to obtain an ACGME-accredited residency position without having to sit out a year.

Important limitations:

• You may submit up to 45 applications to unfilled programs
• Applications are locked in once submitted
• You cannot send new personal emails or call programs to solicit interviews or positions during SOAP (this is an NRMP violation)
• Only certain applicants are SOAP-eligible, determined by NRMP

Understanding what is SOAP early lets you plan your steps months before Match Week instead of scrambling when the list of unfilled positions appears.

1.2 SOAP Eligibility Essentials for Non-US Citizen IMGs

To participate in SOAP, you must:

• Be registered for the NRMP Main Match
• Be eligible to start residency on July 1 (ECFMG certified or expected by that time)
• Be unmatched or partially matched as reported on Monday of Match Week
• Be a graduate of an accredited international medical school recognized by ECFMG

As a non-US citizen IMG, pay close attention to:

• ECFMG certification timing: Delays in Step 2 CK results, missing OET or other requirements can make you ineligible for SOAP.
• Visa status: If you are on a current US visa (F-1 OPT, J-1 research, H-4, etc.), make sure your documentation and timelines will allow residency start on time.

If you are not SOAP-eligible, you can still pursue post-match positions outside SOAP later, but those are much fewer and highly uncertain.

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2. EM–IM Combined: Special Considerations for SOAP Strategy

2.1 Reality Check: EM–IM Combined Programs and SOAP

EM–IM combined (Emergency Medicine–Internal Medicine) is a small, highly selective niche. On SOAP day, it is uncommon to see many EM–IM combined spots unfilled. Most commonly:

• EM–IM combined programs fill in the Main Match
• Occasional unfilled EM–IM positions may exist, but are rare and highly competitive

For a non-US citizen IMG, especially a foreign national needing a visa, the odds of landing an EM–IM combined slot through SOAP alone are low—but not zero.

Implications for SOAP preparation:

• You cannot design a SOAP strategy only around EM–IM combined spots; you must build adjacent pathways:
  • Categorical Internal Medicine (IM)
  • Categorical Emergency Medicine (EM) (if available to IMGs and visa-friendly)
  • Preliminary Medicine or Transitional Year as a bridge
• You must be ready to quickly pivot towards options that keep you clinically active and competitive for a future EM–IM re-application or fellowship.

2.2 Adjacent Pathways for the EM–IM-Oriented Applicant

If your long-term goal is to practice both acute care and comprehensive internal medicine, you can keep that direction alive even if SOAP doesn’t offer an EM–IM combined slot.

Pathway A: Categorical Internal Medicine

• Target IM categorical positions that support hospitalist, critical care, or emergency care interests
• Seek programs with:
  • Strong ICU and ED exposure
  • Opportunities for ED electives
  • Faculty involved in EM, critical care, or acute care research
• Later pathways:
  • Chief year, Hospital Medicine, Pulmonary/Critical Care, or EM-focused roles in some settings

Pathway B: Categorical Emergency Medicine

• Less common for non-US citizen IMGs due to visa and competitiveness, but if EM spots appear unfilled:
  • Check visa sponsorship history carefully
  • Highlight any IM and inpatient experience, as it fits well with EM–IM-style practice.
• Later pathways:
  • Fellowship in Critical Care, Ultrasound, Toxicology, or EM-based Internal Medicine consult roles in some systems

Pathway C: Preliminary IM or Transitional Year

• Consider this if no categorical IM/EM option is realistic.
• Strategic use:
  • Build US clinical experience
  • Obtain strong US letters of recommendation
  • Improve Step scores (Step 3) and research output while in clinical training
• Use that year to re-apply more competitively to EM–IM, EM, or IM.

The core idea: SOAP is about securing a viable path, not just a dream label. As an EM–IM aspirant, a strong IM or EM position can keep your long-term goals alive.

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3. Pre-SOAP Preparation Timeline: Month-by-Month Guide

SOAP preparation should begin well before Match Week, ideally 3–4 months in advance. Below is a practical timeline tailored to a non-US citizen IMG with EM–IM interests.

3.1 3–4 Months Before Match Week

1. Confirm Certification Pathway

• Ensure all ECFMG steps are on track:
  • Step 1, Step 2 CK (and OET if applicable) completed
  • Any pending documents submitted
• If Step 3 is done, this is a major advantage as a foreign national medical graduate, especially for IM and EM programs and for visa sponsorship.

2. Audit Your ERAS Application

• Review:
  • CV, Personal Statement (PS), Experiences, and LoRs
• Identify weaknesses:
  • Gaps in training
  • Low or failed scores
  • Limited US clinical experience
• Plan how to frame these honestly but positively in SOAP communications and interviews.

3. Draft SOAP-Focused Personal Statements

You may need multiple PS versions ready:

• EM–IM / EM-focused PS
• IM-focused PS
• Prelim/Transitional PS

Don’t wait until SOAP week to create these. Use language that shows:

• Clear understanding of emergency medicine internal medicine interfaces
• Appreciation of continuity of care + acute care
• Respect for systems-based practice and interdisciplinary teams

3.2 2 Months Before Match Week

1. Build a Preliminary SOAP Target List

While you won’t know which programs will be unfilled, you can:

• Identify IM and EM programs historically friendlier to IMGs
• Look for programs that:
  • Publicly state they sponsor visas (J-1/H-1B where applicable)
  • Have a history of non-US citizen IMG residents
  • Offer critical care, ED, or hospitalist exposure

Create a spreadsheet with:

• Program name and ACGME code
• State and city
• Visa type historically offered
• Notes on EM/ICU exposure, fellowship options
• Competitiveness assessment (high/medium/low)

2. Verify Visa Policies

As a non-US citizen IMG, your SOAP strategy must be visa-aware.

• Visit program websites for statements about:
  • J-1 sponsorship via ECFMG
  • H-1B sponsorship (often requires USMLE Step 3)
• If unclear, look at current residents’ backgrounds:
  • Are there non-US citizen IMGs?
  • Are their medical schools foreign?

Programs that historically do not sponsor any visas should be low priority in your SOAP list.

3.3 1 Month Before Match Week

1. Refine Personal Statements and CV

• Create final versions of your IM, EM, and prelim personal statements
• Adapt your ERAS Experience descriptions to emphasize:
  • Acute care exposure
  • ED/ICU rotations
  • Leadership roles (codes, rapid response teams, triage)
• Have a mentor or advisor (ideally US-based) review your documents.

2. Practice Short, SOAP-Style Interviews

SOAP interviews are often:

• Short (10–20 minutes)
• Conducted virtually (phone or video)
• Focused on:
  • Red flags (gaps, failures, previous unmatched cycles)
  • Communication skills
  • Fit and motivation

Practice answering:

• “Tell me about yourself” with an EM–IM lens
• “Why emergency medicine internal medicine combined or IM/EM?”
• “Why did you go unmatched?” (if applicable)
• “How will you manage the demands of our program as a foreign national medical graduate with visa needs?”

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4. Match Week: Step-by-Step SOAP Execution

4.1 Monday Morning: When You Learn Your Match Status

On Monday, you receive one of four messages from NRMP. If you are:

• Unmatched or
• Partially matched (e.g., matched to an advanced position but no prelim, or vice versa)

…and are registered for the Match, you may be SOAP-eligible.

Immediate actions:

1. Confirm SOAP eligibility on NRMP.

2. Log into ERAS and ensure:

   • Contact info is current
   • Preferred phone and email are accessible
   • Time zone considerations (if you are abroad) are built into your schedule

3. Emotionally reset:

   • Give yourself 1–2 hours to process disappointment.
   • Then treat this as a high-stakes, time-limited project.

4.2 Monday Midday: Analyzing the List of Unfilled Positions

NRMP releases the List of Unfilled Programs (Dynamic List) to SOAP-eligible candidates.

Key tasks for an EM–IM-oriented, non-US citizen IMG:

1. Filter by Specialty:

   • Emergency Medicine–Internal Medicine combined (if any)
   • Categorical Internal Medicine
   • Categorical Emergency Medicine
   • Preliminary Medicine / Transitional Year

2. For each potential program:

   • Check visa sponsorship quickly (using pre-researched info + website)
   • Note programs already on your pre-SOAP spreadsheet
   • Prioritize those with:
     • Known visa support for foreign national medical graduates
     • Existing non-US citizen IMG residents
     • Strong acute care training

3. Assess your realism:

   • If your Step scores, attempts, or gaps are significant, favor:
     • Community IM programs with documented IMG history
     • Less competitive geographic areas
     • Programs with multiple unfilled positions

4.3 Monday Afternoon: Finalizing Your Application Strategy

You can apply to up to 45 programs total during SOAP.

Strategic allocation for an EM–IM-focused, non-US citizen IMG might look like:

• 0–5 EM–IM combined (if available and visa-friendly)
• 15–25 categorical Internal Medicine
• 5–10 Emergency Medicine (only if your profile is competitive and visa possible)
• Remainder: Preliminary Medicine / Transitional Year

Avoid applying only to dream academic EM or EM–IM programs if your profile is marginal; this can lead to zero interviews.

Program tiering example:

• Tier 1 (Top Fit / Realistic Stretch)

  • IM programs with strong ED/ICU, documented IMG friendliness
  • Any EM–IM combined positions that sponsor visas

• Tier 2 (Solid/Realistic)

  • Community IM programs with many IMGs
  • Prelim Medicine programs in IMG-friendly hospitals

• Tier 3 (Safety/Last Resort)

  • Transitional Year or one-year positions in less popular locations

Distribute your 45 applications across tiers, leaning toward Tier 2 if in doubt.

4.4 Tuesday to Thursday: Interviews and Offers

During SOAP:

• Programs review applications on Tuesday
• Interviews usually take place Tuesday–Wednesday (sometimes Thursday)
• NRMP conducts multiple Offer Rounds from Wednesday onwards

Interview tips for non-US citizen IMGs:

• Be ready to answer visa questions clearly:

  • Current status, need for J-1 or H-1B, Step 3 completion

• Emphasize:

  • Ability to adapt rapidly to US healthcare
  • Strong clinical skills in both acute and longitudinal care
  • Teamwork and communication (critical for EM and IM)

• From an EM–IM perspective, highlight:

  • How you think across differential diagnoses in both ED and ward settings
  • Cases where you managed patients from initial resuscitation through inpatient care

Offer rounds:

• You may receive multiple simultaneous offers in a round.
• You have a limited time window (e.g., 2 hours) to accept one.

Prioritize:

1. Categorical positions over prelim, if you have no other guaranteed pathway.
2. Programs that can realistically sponsor your visa.
3. Positions that keep you close to EM/IM practice (e.g., IM with strong acute care, ED access).

Once you accept an offer, you are committed to that program.

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5. Key Challenges for Non-US Citizen IMGs – And How to Navigate Them

5.1 Visa Complexity

As a foreign national medical graduate, your SOAP options are constrained by:

• Programs that do not sponsor visas at all
• Programs that sponsor only J-1
• Programs that may sponsor H-1B but require Step 3 and early planning

Actionable steps:

• Before SOAP: know your visa priority (J-1 vs H-1B) and constraints.
• During SOAP:
  • Quickly eliminate programs known not to accept any non-US citizens.
  • Prioritize J-1-friendly programs if you don’t yet have Step 3.

5.2 Time Zone and Communication Barriers

If you are physically outside the US:

• Set your phone to US time zones and keep it active 24/7 during SOAP days.
• Ensure:
  • Stable internet for video interviews
  • Backup audio-only option (phone or WhatsApp/VOIP if allowed)
• Check email every 10–15 minutes during interview days.

Consider using a US-based phone number (e.g., Google Voice) that forwards to your current number to avoid international dialing issues.

5.3 Explaining Unmatched or Red Flags

Programs may ask:

• “Why do you think you did not match?”
• “Can you explain this exam attempt / gap?”

Prepare concise, honest explanations focused on:

• Insight gained
• Concrete steps you’ve taken to improve
• Evidence of recent strong performance (recent rotations, research, Step 3, etc.)

For example:

“I believe I did not match primarily because my initial US application was too EM–IM-focused and did not cast a broad enough net in Internal Medicine programs. Since then, I’ve strengthened my inpatient skills through additional observerships, completed Step 3, and refined my communication skills. I’m now more flexible and fully committed to building a strong foundation in Internal Medicine with a focus on acute care.”

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6. Long-Term Perspective: If SOAP Doesn’t Yield the Ideal EM–IM Outcome

Even with excellent SOAP preparation, you may:

• Match into IM or EM rather than EM–IM, or
• Obtain only a prelim position, or
• Remain unmatched after SOAP

6.1 If You Match in IM or EM

This is often a success, not a failure.

• Use residency to:
  • Build robust acute care skills
  • Pursue ED, ICU, and rapid response experiences
  • Engage in research at the intersection of EM and IM
• After residency, explore:
  • Hospitalist + ED roles
  • Critical care or other EM/IM-adjacent fellowships

6.2 If You Match in a Prelim or Transitional Year

Treat it as a launching pad:

• Maximize:
  • Clinical performance and evaluations
  • US letters from ED/ICU attendings
  • Quality improvement or research projects

Plan a strategic reapplication:

• Expand to more IM and EM programs
• Use your new US-based CV strength to improve your profile
• Consider taking Step 3 early, if not already done, for H-1B flexibility.

6.3 If You Remain Unmatched After SOAP

This is extremely difficult emotionally, but you still have options:

• Look for post-SOAP open positions (rare but possible)
• Consider research positions in EM or IM departments in the US
• Build additional US clinical experience and strengthen your profile
• Reassess your specialty range; some foreign national medical graduates successfully pivot to broader IM or Family Medicine with strong acute care elements.

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FAQ: SOAP Preparation for Non-US Citizen IMGs in EM–IM

1. As a non-US citizen IMG interested in EM–IM combined, should I still apply mostly to EM–IM programs during SOAP?
No. EM–IM combined positions very rarely remain unfilled. During SOAP, prioritize categorical IM programs, with selective applications to any available EM–IM or EM programs that clearly support non-US citizen IMGs. Think of SOAP as securing a viable path into acute and internal care, not only a labeled “EM–IM” spot.

2. How important is Step 3 for SOAP as a foreign national medical graduate?
Step 3 is highly valuable, especially if you hope for H-1B sponsorship. Many IM and EM programs prefer or require Step 3 completed before residency for H-1B. Even for J-1, having Step 3 strengthens your application and signals readiness. If possible, complete Step 3 before the Match cycle or before SOAP.

3. What can I do if there are no visa-sponsoring programs left in SOAP for EM or IM?
If visa-sponsoring EM and IM categorical positions are absent or too competitive, consider:

• Prelim Medicine or Transitional Year programs that sponsor J-1
• Building a profile through US research or non-clinical positions to reapply next year
• Seeking professional advice from IMG support organizations or mentors

You must ensure that any position you accept allows you to legally remain in the US and start residency.

4. Is it acceptable to change my personal statement focus from EM–IM to pure IM for SOAP applications?
Yes, and it is often necessary and wise. You should have at least one IM-specific SOAP personal statement ready. You can still mention your interest in acute care and ED work, but your message must show clear and genuine commitment to Internal Medicine (or Emergency Medicine) as it stands, not as a temporary backup.

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By preparing months in advance, understanding what SOAP really is, and aligning your strategy with the realities of EM–IM combined training and visa constraints, you can use SOAP not just as damage control, but as a structured, high-yield second chance to enter a path that ultimately leads you to practice the kind of medicine you love.