SOAP Strategy: Prioritizing Remaining Spots in Least Competitive Specialties

It’s 11:05 AM on Monday of Match Week. The email just hit: “We are sorry to inform you…” Your stomach drops. You log into NRMP, see the word “Unmatched,” and then that timer at the top of the page starts to feel like it’s ticking directly in your ears.

At 11:00 AM ET tomorrow, the SOAP applications open. You’ll get that unfilled positions list. It’ll be hundreds of spots long, across dozens of specialties you maybe half-considered in MS2 and then promptly forgot.

You have limited applications. Limited time. And suddenly you’re trying to play 4D chess with your career.

You’re in exactly the situation this article is built for: you’re going into SOAP, you need a realistic shot at matching, and you’re looking at least competitive specialties and thinking:

“Where do I aim first so I don’t blow this?”

Let’s walk through how to prioritize those remaining spots in the least competitive fields without panicking, wishful thinking, or wasting your applications.

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First Reality Check: SOAP Is Not The Regular Match

Before we talk specialties, you need to understand the game you’re actually playing.

During the main Match, programs are picky and idealistic. During SOAP, some of that goes out the window. They now have:

• Empty spots they must fill
• A compressed timeline
• Hundreds of panicked applicants bombing them with ERAS

So a few truths you need to tattoo on your brain:

1. You are not “competing for a specialty” right now. You’re competing for a seat. Any seat.
   The question is not “What do I love?” It’s “Where am I most likely to get an offer this week?”

2. Your leverage is low, but not zero.
   You choose where to apply and how realistic you’re being. That’s your power. Use it.

3. Programs are sorting fast and crude.
   Filters. Red flags. “Do we know this school?” “Any local connection?” “Are they clearly desperate or actually interested?”

SOAP success is about matching your profile to the right tiers of least competitive specialties, then being extremely deliberate with your application order.

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Know Your SOAP-Friendly “Least Competitive” Specialties

“Least competitive” is not an insult. It’s a reflection of how many applicants fight for each seat, how high average scores are, and how many spots routinely go unfilled.

In SOAP, certain specialties show up over and over. These are the workhorses of the unfilled list.

Here’s a rough tiering of specialties that often show up with unfilled positions and can be realistic routes for unmatched applicants.

Specialty	Usual Competitiveness	SOAP Presence
Family Medicine	Least competitive	Heavy, every year
Internal Medicine	Low–moderate (community)	Heavy, mostly community
Pediatrics	Low–moderate	Moderate
Psychiatry	Rising, still moderate	Moderate–light
Pathology	Low–moderate	Small–moderate
Neurology	Moderate	Small–moderate

There are others depending on the year (prelims, transitional year, IM subspecialty prelims, occasional OB/Gyn, etc.), but if you’re trying to prioritize, those six are your core shopping list.

Now let’s get practical and situation-specific.

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Step One: Brutal Self-Assessment in 10 Minutes

Before the list even drops, you need a profile snapshot. No fluff. No “but I worked so hard.” Programs do not care during SOAP.

You need to decide which pond you’re realistically fishing in.

Sit down with a piece of paper (yes, old-school) and write:

1. Step scores / COMLEX scores
2. Any failures (Step 1, Step 2, COMLEX, course failures, repeats)
3. Med school type: US-MD, US-DO, Caribbean/IMG, etc.
4. Graduation year (fresh vs older)
5. Red flags: leaves of absence, professionalism issues, legal issues
6. What you applied for originally (and how far that is from FM/IM/Peds/Psych)
7. Geographic ties (home state, med school state, places you’ve lived/worked)

Then categorize yourself bluntly:

• Tier A: US-MD or strong US-DO, no exam failures, decent scores (Step 2 in 220s+ USMLE or COMLEX equivalent), fresh grad, applied to moderately competitive specialty originally (e.g., EM, Gas, Rads)
• Tier B: US-DO or average US-MD, maybe one exam hiccup but overall pass, applied to competitive or moderate specialties, or marginal scores
• Tier C: US-IMG or non-US IMG, older grad, multiple exam attempts, or significant red flags

Why this matters: your tier determines how “safe” your SOAP strategy needs to be.

If you pretend you’re Tier A when you’re firmly Tier C, you waste your best shot chasing mirages.

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Step Two: Understanding the Personality of Each “Least Competitive” Specialty

Now we connect who you are to what these specialties actually look for, especially in SOAP.

Family Medicine: The Workhorse, Your Baseline Safety Net

If you’re in SOAP and your main priority is any categorical seat, Family Medicine is almost always your anchor.

Patterns I’ve seen over and over:

• Community FM programs consistently show up with unfilled spots.
• Many are in less desirable locations (rural Midwest, deep South, rust belt towns).
• They’re relatively forgiving of:
  • Lower scores
  • IMGs
  • Non-traditional paths
  • Step failures (depending on program)

FM is where you should default your safest applications.

• Tier A/B applicants: FM can be your absolute safety, but that doesn’t mean it is guaranteed.
• Tier C applicants: FM should be heavily represented in your list, especially in states that historically fill late or are IMG-friendly (Indiana, Ohio, Michigan, parts of Texas, Midwest generally).

If you’re not applying to any FM programs during SOAP and you have red flags, you’re playing with fire.

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Internal Medicine (Community): The Realistic Upgrade

Academic IM is not “least competitive.” But community IM programs, especially in less popular regions, absolutely are SOAP-friendly.

Things you’ll typically see:

• Happier with US grads but many will interview DOs and IMGs.
• More score-sensitive than FM but still flexible, especially if you have:
  • Decent Step 2
  • No major professionalism problems
  • Some IM exposure (rotations, letters)

If you’re Tier A or B, and you’d genuinely like internal medicine, you can aim a significant chunk of your SOAP shots here.

Tier C: pick IM wisely, prioritize programs that historically take IMGs / DOs or are in less popular areas. Do not make IM the majority of your list unless you have real evidence it’s within reach (e.g., decent scores, US-IMG from a known school, solid IM letters).

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Pediatrics: Underrated and Frequently Overlooked

Peds shows up with fewer unfilled spots than FM or IM, but it’s often a bit less crowded applicant-wise because a lot of unmatched EM/GS/Ortho folks don’t even consider it.

Real talk about Peds in SOAP:

• They care massively about “fit” and genuine interest.
• They’re less score-obsessed than IM but not as forgiving as FM for repeated failures.
• They like:
  • Evidence you like working with kids: peds rotations, volunteer work, a peds letter
  • A personal statement that isn’t obviously recycled from Surgery

Tier A/B applicants who can plausibly sell a pediatrics narrative should absolutely include some peds programs. This is often a sweet spot: less applicant volume than IM, more structure than FM.

Tier C: still possible, but you need something to show them—at least one peds rotation, a letter, something.

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Psychiatry: Hotter Every Year, Still an Angle

Psych used to be a gimme. Not anymore. It’s rising fast. But in SOAP you’ll often see:

• A few scattered community psych programs
• Programs in regions that are hard to recruit to
• Programs more open to DOs and IMGs than Radiology or Ortho will ever be

If you have:

• Clear psych interest (rotations, electives, a psych letter)
• A reasonable Step 2 (220s+ ideally, or COMLEX equivalent)
• No major professionalism flags

Then psych is a realistic target for Tier A and some Tier B applicants.

But do not kid yourself: if you’re Tier C with multiple fails and no psych experience, this is not your “back-up easy specialty.” It isn’t that anymore.

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Pathology: Great Fit For Some, Terrible Random Backup

Pathology shows up in SOAP some years more than others. It’s relatively low-competition in the main match, but in SOAP it’s niche.

Programs care about:

• Fit with lab-based, analytic work
• Genuine interest (ideally pathology electives, a path letter)

If you’ve never done a path elective, have zero path exposure, and you’re just clicking “apply” because “hey, fewer applicants,” you’re not thinking like a program director. They will see right through that.

This is a fantastic SOAP specialty if:

• You already knew you liked path but applied to something else first (e.g., IM with the idea of heme/onc, then pivot)
• You have pathology shadowing, electives, or a letter

Otherwise, move it down your priority list unless you’re truly desperate for any seat and have exhausted FM/IM.

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Neurology: Middle-of-the-Road but Occasionally Accessible

Neurology sits in a weird middle ground. Not ultra-competitive like Derm, not wide-open like FM.

In SOAP you might see:

• A handful of unfilled spots
• Programs needing applicants but with at least moderate score expectations

Neurology likes:

• Solid Step 2 (often 220s+ USMLE or equivalent)
• Some neuro exposure (stroke, epilepsy, inpatient consults)
• People who can articulate why neurology—and not just “I need a job”

This is usually a Tier A / strong Tier B rescue lane, not a Tier C safety. Don’t anchor your survival plan on neurology if your transcript is full of landmines.

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Step Three: Building a SOAP Application Priority Strategy

Now the real question: how do you actually rank your effort across these specialties?

You get a finite number of applications during SOAP. You can’t carpet-bomb everything. You must prioritize.

Here’s how I’d structure it, based on your tier.

If You’re Tier A (Strong Applicant, Just Unlucky or Switched Late)

Profile: US-MD or strong DO, no fails, solid Step 2, originally applied to a competitive/moderately competitive specialty.

Your play:

• Anchor specialties: Community Internal Medicine, Pediatrics, Psychiatry
• Safety net: Family Medicine
• Selective shots: Neurology, Pathology (only if real interest/evidence)

Approximate split (varies by your interests):

• 40–50% community IM
• 20–25% Peds
• 10–20% Psych
• 10–20% FM
• 0–10% Neuro/Path depending on history

Your mistake to avoid: sending too many applications to “dreamier” programs or academic-heavy IM and not enough to FM/Peds/true community IM.

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If You’re Tier B (Mixed Bag, Some Weaknesses But Not Sunk)

Profile: US-DO or average US-MD, maybe one exam issue, moderate scores, or applied to a stretch specialty.

Your play:

• Anchor specialties: Family Medicine & Community Internal Medicine
• Moderate shot: Pediatrics
• Selective psych: Only where you clearly fit
• Path/Neuro: Only if you have a story and evidence

Rough split:

• 40–50% FM
• 25–30% Community IM
• 10–20% Peds
• 5–10% Psych (if real interest)
• Remainder in any Path/Neuro with clear fit

Your mistake to avoid: underweighting FM because of ego. I’ve watched people in this band skip FM, overshoot with IM/Psych, and end up completely unmatched.

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If You’re Tier C (Multiple Red Flags, IMG, Older Grad)

Profile: US-IMG or non-US IMG, multiple Step/COMLEX attempts, older graduation, or significant other issues.

Your play:

• Primary survival lane: Family Medicine
• Secondary lane: IM in very specific, IMG-heavy, less-desirable regions
• Occasional: Pediatrics, only where IMGs/older grads are clearly welcomed

Your approximate split:

• 60–80% FM (yes, that high)
• 20–30% highly targeted Community IM (using filters: IMG-friendly, prior unmatched, rural areas)
• Maybe 0–10% Peds if you have strong peds evidence and know those programs take IMGs

You do not have the luxury of fantasy. The question is: do you want a residency this year or do you want to gamble on reapplying?

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Step Four: Within a Specialty, How Do You Rank Programs?

Not all FM or IM programs are equal in how likely they are to take you in SOAP.

When the unfilled list drops, you’ll be tempted to panic-apply. Don’t.

Use a 3-pass system:

SOAP Program Prioritization Flow

Step	Description
Step 1	Unfilled List
Step 2	First Pass - Hard Filters
Step 3	Geography You Accept
Step 4	Visa and IMG Status
Step 5	Exclude Absolutely No
Step 6	Second Pass - Competitiveness Read
Step 7	Community vs Academic
Step 8	Historic IMG DO Friendly
Step 9	Third Pass - Personal Fit
Step 10	Finalize Priority List

First pass: Hard filters

• States you absolutely cannot or will not live in? Be honest, but not picky. SOAP is not the time to be snobby about towns and weather.
• Visa requirements if you’re an IMG needing sponsorship
• Programs explicitly requiring no exam failures if you have fails

Cross off the truly impossible. Not the “I’d rather not.” The impossible.

Second pass: Competitiveness read

Signs a program will be less picky:

• Community hospital, not big-name academic center
• Rural or smaller city
• Historically lower fill rates
• Known to take DOs/IMGs in the main Match

Signs a program might be out of reach during SOAP:

• Top-tier academic center
• Prestigious metro area, well-known name
• Historically 100% fill rate and strong reputation

Push the more forgiving ones higher.

Third pass: Personal fit and narrative

If you can show:

• Geographic ties (“Grew up in Ohio, medical school in Indiana, family in Michigan”)
• Specialty-relevant rotations or sub-I’s at similar institutions
• A believable reason you’d stay there for three years

That program climbs your internal priority list.

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Step Five: Messaging by Specialty So You Don’t Sound Desperate

Your personal statement and communications must match the specialty you’re applying to, especially in SOAP. Generic “I just want to help people” language is a red flag.

No, you can’t write four totally custom novels overnight. But you can create 2–3 concrete specialty-focused versions:

• FM / IM version
• Peds version
• Psych / Neuro / Path (if needed) version

The trick: drop the original specialty from your story. Do not spend half the essay explaining why you didn’t match Dermatology. That’s dead weight.

Instead:

For Family Medicine:

• Emphasize continuity, broad scope, community medicine, rural/underserved interest
• Mention outpatient rotations, clinic experiences, primary care exposure

For Internal Medicine:

• Emphasize complex problem-solving, inpatient medicine, longitudinal adult care
• Talk about your IM rotations, consult services, interest in hospital-based medicine or subspecialty down the line

For Pediatrics:

• Emphasize communication with families, growth and development, vulnerable populations
• Mention specific patient encounters with children that changed your practice

For Psychiatry:

• Emphasize listening, longitudinal relationships, mind–body intersection
• Mention psych rotations, addiction experience, mental health interest

For Pathology:

• Emphasize analytic thinking, love of patterns, foundational diagnostics
• Talk about any lab research, path lectures you enjoyed, or relevant electives

You don’t have time for perfection. You do have time to avoid sounding like you blindly applied to 45 random programs.

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Step Six: What You Do While Programs Are Reviewing

After applications go in, people make one of two mistakes:

• Freeze and stare at their inbox
• Spam programs with emails and calls that make them look unhinged

You should instead:

• Have an updated, SOAP-appropriate CV ready in case a program asks
• Keep your phone on you at all times, with voicemail cleared and a professional voicemail message recorded
• Continue to refine your quick “Why this specialty, why this program, why now?” pitch in your head

If you email programs, keep it tight and rational:

• One brief email to a small number of top-priority programs where you have genuine ties
• 3–5 sentences explaining:
  • Who you are
  • That you applied via SOAP
  • Your connection to them (geography, alumni, rotation, etc.)
  • Your sincere interest

Do not send 100 identical desperate emails. It reads exactly like you think it does.

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Where You Land After This Week

Right now, your horizon is 72 hours long. I get it. But the way you handle SOAP—especially how you prioritize these “least competitive” specialties—sets you up for one of three futures:

1. You match into a field you hadn’t originally planned but can absolutely build a real career in (FM, IM, Peds, Psych, Path, Neuro).
2. You match somewhere less than glamorous geographically, finish strong, then shape your long-term path with fellowships or job choices later.
3. You do not match, but you at least walk away knowing you played the strategy correctly, which makes your reapplication plan much clearer.

If you’re in SOAP, you’re in crunch time. You cannot control who calls you, but you can absolutely control whether you aimed your applications where they were most likely to stick.

Use FM and community IM as your foundation. Layer in Peds and Psych where the fit is real. Treat Path and Neuro as targeted, not random, add-ons. And be honest with yourself about your actual tier, not the one you wish you were in.

This week is about getting into the game. Training, fellowships, subspecialties, reshaping your path—that all comes later. For now, your job is to walk out of SOAP with a contract in hand and a path forward.

Once you have that, then we can talk about how to thrive in the specialty you landed in—even if it was not the one you circled on your MS1 dream board. But that’s the next chapter, not this one.