SOAP Preparation Guide for Non-US Citizen IMGs in General Surgery

Understanding SOAP for the Non‑US Citizen IMG in General Surgery

For a non-US citizen IMG aiming for a general surgery residency, the Supplemental Offer and Acceptance Program (SOAP) can be both a second chance and a high‑pressure sprint. To use it effectively, you must understand not only what is SOAP but also how your immigration status and IMG background change your strategy.

What Is SOAP, In Practical Terms?

SOAP is a structured, four‑day process during Match Week that allows unmatched or partially matched applicants to obtain unfilled residency positions before the public post‑Match scramble.

Key features:

• Eligibility:
  You must be:

  • Registered for the Match, and
  • Either fully unmatched, or partially matched (e.g., matched to a prelim but not categorical) and eligible for more positions, and
  • Certified by ECFMG before SOAP begins (for IMGs).

• Timeline:
  Exact times change slightly each year, but the flow is:

  1. Monday 10:00 a.m. ET:
     NRMP releases match status (matched / partially matched / unmatched). If you’re eligible, you get access to SOAP.
  2. Monday 10:00 a.m. – 11:00 a.m. ET:
     ERAS opens the list of unfilled programs and allows you to begin applications.
  3. Monday 11:00 a.m. – Tuesday morning:
     You can submit up to 45 applications through ERAS to participating SOAP programs.
  4. Tuesday–Thursday:
     Up to four “Rounds” of offers. Programs review applications and conduct interviews electronically/phone/video; offers are sent in timed rounds.

• Max 45 Applications:
  You cannot exceed this during SOAP. For a non-US citizen IMG targeting general surgery, how you allocate these 45 is critical.

• Communication Rules:

  • You may not contact programs directly to solicit interviews or offers.
  • Programs must initiate contact during SOAP.
  • Violation can lead to NRMP violations.

What SOAP Means Specifically for a Non‑US Citizen IMG in General Surgery

General surgery is one of the more competitive specialties, and during SOAP:

• Many unfilled general surgery positions are preliminary, not categorical.
• Categorical general surgery SOAP spots are rare and highly competitive.
• Many programs do not sponsor visas during SOAP, even if they do during the main cycle, due to time pressure and paperwork.

Implication: As a foreign national medical graduate, you must enter SOAP pre‑filtered for:

• Visa feasibility (J‑1 vs H‑1B),
• ECFMG certification status,
• Realistic competitiveness for general surgery vs considering related backup specialties (e.g., prelim surgery, prelim medicine, transitional year).

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Pre‑SOAP Preparation: What You Must Have Ready Before Match Week

Your SOAP preparation should start months before Match Week. Waiting until Monday of Match Week is a major disadvantage.

1. Ensure ECFMG Certification and Visa Readiness

For a non-US citizen IMG, your eligibility and attractiveness to programs depend heavily on two documents: ECFMG certification and visa documentation.

ECFMG Certification

You must:

• Have passed USMLE Step 1 and Step 2 CK and met all ECFMG requirements.
• Have your status updated to “ECFMG Certified” before SOAP begins.

Action steps:

• Track your ECFMG status at least 2–3 months before Match.
• Follow up promptly on any missing primary source verifications or documents.
• Ensure your medical school diploma and transcript have no pending issues.

If your certification delays push into Match Week, many programs will automatically filter you out.

Visa Strategy: Be Clear and Consistent

You are a foreign national medical graduate, so programs will scrutinize visa needs.

Common scenarios:

• J‑1 Visa (via ECFMG):

  • Most IMG‑friendly surgery programs that sponsor visas prefer J‑1.
  • Requirements: ECFMG Certification; a contract with a GME program.
  • SOAP‑friendly because it is faster/higher volume than H‑1B for surgery.

• H‑1B Visa:

  • Fewer general surgery programs sponsor H‑1B (especially during SOAP).
  • Requires:
    • USMLE Step 3 passed before visa filing in most states/institutions.
    • Extra legal/processing time.

For SOAP preparation:

• Decide if you will accept J‑1 sponsorship if offered during SOAP. If yes, state it clearly in your application materials.
• If you insist on H‑1B, recognize this drastically shrinks your pool of SOAP programs.

Document preparation:

• Have a concise “Visa Status” line ready for your CV and emails:
  • Example: “Foreign national IMG, ECFMG certified, requiring J‑1 visa sponsorship; Step 3 planned/complete (if applicable).”
• Keep digital copies of passport, US visas, I‑20/DS‑2019 (if applicable) organized, in case programs request them quickly.

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2. Optimize Your Application Materials for SOAP

You will use the same ERAS account during SOAP, but how your materials are tailored and updated can influence whether surgery programs take a second look at you.

ERAS Application Review

Before Match Week:

• Audit your ERAS for errors or vague entries.
  • Clarify clinical experiences in the United States.
  • Emphasize surgery‑relevant experiences (rotations, electives, observerships).
• Update any new:
  • Publications (especially surgery or research‑heavy).
  • Presentations/posters.
  • US clinical experience (USCE), especially if surgical or ICU.

Focus on “Surgery‑compatible” strengths:

• Strong Step 2 CK.
• Solid surgical clerkship evaluations.
• Hands‑on procedural experience where allowed.
• Evidence of resilience, long hours, and teamwork.

Personal Statement Strategy: Main vs SOAP Version

You may not have time to rewrite everything during SOAP, so prepare at least two versions ahead of time:

1. Primary General Surgery Personal Statement

   • Emphasizes your commitment to a career in surgery, long-term academic or community goals, and fit for categorical positions.

2. SOAP‑Adapted Statement for Prelim/Backup

   • Tailored specifically for:
     • Preliminary general surgery positions, and/or
     • Closely related backup fields (e.g., prelim medicine, transitional year, anesthesia prelim) if you will consider them.
   • Focus: your desire to gain strong clinical and operative foundation while you work toward a future categorical spot.

Key modifications for the SOAP statement:

• Add a clear paragraph addressing:
  • Flexibility about starting as a preliminary resident if needed.
  • Your plan to use a prelim year productively (research, networking, skills).
• Clarify visa flexibility (J‑1 acceptance if true).

Example SOAP line:

“As a non-US citizen IMG, I understand the competitiveness of categorical general surgery and am fully prepared to contribute as a dedicated preliminary surgery resident, using this year to advance my operative skills, academic productivity, and candidacy for a future categorical position.”

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3. Letters of Recommendation and US Clinical Contacts

For SOAP, you typically cannot upload brand new letters mid‑week due to timeline constraints. However, planning now can improve your options:

• Make sure you already have:

  • At least 2–3 strong Letters of Recommendation from surgeons, ideally US‑based.
  • One letter may be from a non‑surgical field (e.g., critical care, internal medicine) if it aligns with your backup plans.

• If you recently completed a sub‑internship or observership in surgery:

  • Ask your attendings if they would be comfortable taking a call from programs during SOAP.
  • You cannot initiate these calls yourself, but having supportive attendings aware of your SOAP plans is useful.

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Building a SOAP Strategy as a Non‑US Citizen IMG in General Surgery

You will not have the luxury of figuring out your strategy on Monday morning; you need to create a structured SOAP plan in advance.

1. Researching Likely SOAP Programs

You can’t see SOAP openings before Match Week, but you can predict probable patterns using:

• Past years’ unfilled program lists (from NRMP or forums).
• Program websites with a track record of:
  • Accepting IMGs,
  • Sponsoring visas (especially J‑1),
  • Offering preliminary general surgery positions.

Create a spreadsheet with these columns:

• Program name and ACGME code
• Location and hospital type
• Visa policy (J‑1 only, J‑1 + H‑1B, no visa)
• Historically IMG‑friendly? (Y/N; note patterns from current roster)
• Position types (categorical vs preliminary)
• Notes on program culture, operative exposure, fellowship placements

Mark:

• High Priority: Visa‑friendly, IMG‑friendly general surgery programs, especially categorical (rare).
• Medium Priority: Prelim general surgery in visa‑friendly institutions; strong clinical/research environment.
• Low Priority / Backup: Other prelim or transitional year options only if you are willing to accept them.

2. Allocating Your 45 SOAP Applications

As a foreign national IMG targeting general surgery, you must avoid the trap of “hoping” for 45 categorical surgery options. They may not exist.

A balanced allocation example for a non-US citizen IMG with solid but not top-tier scores might be:

• 5–10: Categorical general surgery (if available, especially community programs known to take IMGs and sponsor J‑1).
• 20–30: Preliminary general surgery positions in visa‑friendly settings.
• 5–10: Prelim medicine or transitional year programs that:
  • Are IMG‑friendly,
  • Sponsor J‑1,
  • Have strong ICU/operative exposure or ties to surgery departments.

If your profile is very competitive (high Step scores, strong US surgery experience, research), you may reverse that emphasis—more categorical attempts. If your profile is weaker, shift more heavily into prelim opportunities.

Key principle:
Apply only where your visa status is feasible. Do not waste applications on programs that explicitly exclude non‑US citizens or do not sponsor any visas.

3. Deciding on Prelim vs Categorical Priorities

You must be honest with yourself about your competitiveness. Ask:

• Are your USMLE scores at or above the average for matched general surgery?
• Do you have recent US clinical experience in surgery?
• Do you have meaningful research, especially in surgery?

If your profile is borderline:

• Treat a preliminary surgery year at a strong program as a realistic and valuable path.
  • It gives you:
    • US operative experience,
    • Stronger letters,
    • Better networking for a future general surgery residency match.

If your profile is quite weak:

• Consider whether a prelim internal medicine or transitional year at an IMG‑friendly institution might better position you over time, especially if it offers:
  • ICU exposure,
  • Procedures,
  • Opportunities to interact closely with surgeons.

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Executing During SOAP Week: Hour‑by‑Hour Priorities

When Match Monday arrives, you must be ready to move with precision.

1. Monday Morning: Status Check and Application Launch

10:00 a.m. ET – NRMP Status Released

If you are:

• Unmatched: You are fully eligible for SOAP.
• Partially matched (e.g., prelim but not categorical): You can still participate if you are eligible for additional positions.

Confirm:

• Your ECFMG certification status.
• Your correct email and phone number in ERAS (for programs to contact you quickly).

10:00–11:00 a.m. ET – Review Unfilled Positions List

Within this hour:

• Pull the NRMP list of unfilled programs that participate in SOAP.
• Filter immediately for:
  • “Surgery – General” (categorical and prelim),
  • Programs that sponsor J‑1 or H‑1B as per your earlier research.

Cross‑reference your spreadsheet:

• Highlight programs that match your visa status and IMG‑friendliness.
• Confirm each listing matches what you planned (program names can change slightly).

11:00 a.m. ET Onward – Submitting Applications

You can now:

• Assign your pre‑selected personal statements (categorical vs prelim version).
• Assign appropriate LoRs.
• Submit applications—remember the 45 maximum.

Tactical tips:

• Do not use all 45 on the first pass unless you are certain you want every single program.
• Keep a small buffer (3–5 slots) in case additional positions appear or you realize you missed a key program.

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2. Communication and Interviews During SOAP

Programs may:

• Request quick phone calls or video interviews.
• Ask clarifying questions about visa status, ECFMG certification, prior clinical experience.

Prepare in advance:

• A 60–90 second elevator pitch focusing on:
  • Who you are (non-US citizen IMG, your medical school, ECFMG certified),
  • Why general surgery is your field,
  • What you bring (USCE, resilience, work ethic),
  • Your visa status concisely.

Example:

“My name is Dr. _____. I am a non-US citizen IMG from [school], ECFMG certified, requiring J‑1 sponsorship. I’ve completed two months of US clinical experience in general surgery and one month in ICU, with strong letters from US surgeons. I’m very interested in developing as a technically strong, team‑focused surgeon, and I believe your program’s operative exposure and supportive faculty would be an excellent fit.”

• Answers to common SOAP‑specific questions, including:
  • Why are you unmatched?
  • Would you accept a preliminary position?
  • If offered a spot, will you commit?
  • How will you manage visa timelines?

Be honest but focused:

• For “Why unmatched?” you might mention:
  • The competitiveness of surgery,
  • Limited number of interviews,
  • Late ECFMG certification,
  • Non‑US citizen status limiting visa‑sponsoring programs.
• Avoid blaming specific programs or people.

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3. Managing SOAP Offers and Rounds

SOAP has up to four offer rounds, each with a time window where you can either accept or reject offers. You may receive:

• Zero offers in a round,
• One offer,
• Multiple offers (less common, but possible).

Key rules:

• If you accept an offer, you are bound to that program and are removed from SOAP immediately.
• If you reject an offer, you may receive another in later rounds, but there are no guarantees.

Decision strategy for a non‑US citizen IMG:

1. Prioritize visa feasibility.

   • If a visa‑sponsoring general surgery prelim or categorical program offers you a spot, that may be significantly more valuable than waiting for a non‑sponsoring or uncertain option.

2. Categorical vs Prelim:

   • A categorical general surgery spot that fits your visa needs is typically a clear “accept.”
   • A preliminary surgery spot:
     • Weigh program quality (operative volume, support, track record of prelims securing categorical spots) and your long‑term goals.
     • If the prelim offer is at a strong institution, accepting early can be wise.

3. Backup vs No Offer:

   • Turning down a reasonable prelim surgery offer in the hope of a future categorical that may never appear is risky, especially for non‑US citizen IMGs, where visas further restrict options.
   • If you already have no other interviews or active interest, a prelim or even a solid transitional year can be a rational choice.

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After SOAP: Planning Your Next Steps as a Foreign National IMG

Whether you match into a surgery position through SOAP or not, you must think strategically about the next 1–2 years.

If You Accept a Preliminary General Surgery Position

Treat this as a one‑year audition:

• Aim for excellent clinical evaluations, especially on high‑exposure rotations (trauma, ICU, chief services).
• Seek mentors early—identify faculty who are supportive of prelims.
• Participate in research projects with surgeons; even small retrospective studies can lead to abstracts or publications.
• Use your US-based work to:
  • Strengthen your CV,
  • Gain stronger LoRs,
  • Understand the culture of US surgical training.

Plan for the next application cycle:

• Decide by mid‑PGY‑1 whether to re‑enter the general surgery residency match for a categorical R1 slot (at your institution or elsewhere).
• Maintain ECFMG paperwork and any visa renewals proactively.

If You Accept a Prelim Medicine or Transitional Year

This can still serve your long‑term surgery goals:

• Seek rotations with heavy procedural/ICU exposure.
• Work with hospitalist and ICU teams that interact with surgeons.
• Explore research opportunities in perioperative care, critical care, or related fields.
• Build relationships with surgeons you meet through shared patients or consults.

Assess over time whether:

• You remain committed to surgery, or
• You begin to see strong alternatives (critical care, anesthesia, hospital medicine), which may provide more stable visa options and long‑term careers.

If You Remain Unmatched After SOAP

This outcome is emotionally difficult but not the end of your career.

Constructive steps:

1. Objective Debrief:

   • Review your application honestly: scores, attempts, graduation year, USCE, research, LoRs, personal statement.
   • Seek feedback from:
     • Program directors who interviewed you (most won’t give detailed feedback, but some will),
     • Faculty mentors in your home institution or US rotations.

2. Targeted Gap Year Plan:

   • Consider a research position in surgery or critical care at a US institution.
   • Seek observerships or externships with hands‑on exposure if possible.
   • Improve your USMLE portfolio (e.g., Step 3 if not already taken, especially if you’re aiming for H‑1B later).

3. Reassessing Specialty and Visa Strategy:

   • Evaluate whether staying strictly with general surgery is realistic for you, given:
     • Competition level,
     • Your scores and YOG,
     • Visa limitations.
   • Some non-US citizen IMGs successfully pivot to:
     • Surgical prelim → categorical in a related field (e.g., anesthesia, radiology, internal medicine with procedural focus).
     • Non-surgical specialties with better visa and match prospects.

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FAQs: SOAP Preparation for Non‑US Citizen IMGs in General Surgery

1. As a non-US citizen IMG, should I even expect categorical general surgery spots in SOAP?
You should hope but not rely on them. Categorical general surgery positions rarely go unfilled, and when they do, they’re highly competitive. Enter SOAP with:

• A prioritized list of any categorical general surgery programs that appear, and
• A realistic plan centered on preliminary surgery positions and possibly prelim medicine or transitional year programs that are visa‑friendly.

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2. Can I change my personal statement or letters during SOAP?
You can reassign existing personal statements and letters to specific applications during SOAP, but you generally cannot upload brand‑new LoRs at the last second. This is why:

• Preparing a SOAP‑specific personal statement (for prelim/backup) in advance is crucial.
• Ensuring strong, surgery-relevant LoRs are already in your ERAS account before Match Week is essential.

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3. How does my visa status affect my SOAP chances in general surgery?
Programs under SOAP face severe time pressure. Many:

• Prefer J‑1 visas (simpler and more familiar for IMGs),
• Avoid H‑1B unless they already have an established process,
• May not sponsor any visas at all during SOAP.

You improve your chances by:

• Clearly indicating that you are ECFMG certified and open to J‑1 sponsorship (if true),
• Applying primarily to programs known to sponsor your visa type,
• Avoiding wasting slots on non-visa programs.

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4. What is SOAP vs “the scramble,” and why does preparation matter more for non-US citizens?
SOAP replaced the old “scramble” with a more structured, electronic process. For non-US citizen IMGs:

• The structured nature means programs are more likely to use filters (ECFMG certification, visa requirements) rigorously.
• You must be fully ready on Monday (application polished, visa details clear, program research done) to have any realistic chance at surgery residency match opportunities through SOAP.
• Poor preparation can mean you burn through your 45 applications on programs that would never consider your visa status, while better‑prepared applicants target realistic, visa-friendly openings.

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By approaching SOAP as a deliberate, data‑driven process—rather than a last-minute scramble—you significantly improve your odds of securing a meaningful position in or near general surgery, even as a non-US citizen IMG.