Step Score Strategy for DO Graduates in Internal Medicine Residency

Understanding How Step Scores Really Matter for a DO Graduate in IM

For a DO graduate targeting an internal medicine residency, Step score strategy is not about chasing perfection—it’s about using the scores you have to create the strongest possible overall application and targeting programs intelligently.

As of today:

• USMLE Step 1 is Pass/Fail, but programs still care how you passed (first attempt vs repeat, timing, COMLEX performance).
• USMLE Step 2 CK and COMLEX Level 2-CE are critical differentiators for the IM match.
• Being a DO graduate adds layers:
  • Some programs are very DO-friendly and used to interpreting COMLEX.
  • Others still prefer or require USMLE scores.
  • Your osteopathic identity can be a strength if you frame it well.

This article focuses on a Step score strategy for DO graduates who want to maximize their chances in the internal medicine residency match (IM match)—especially if you are worried about a low Step score match scenario or feel your scores are “average” rather than stellar.

We’ll cover:

• How programs view DO, COMLEX, and USMLE in internal medicine
• Step 1 and Step 2 CK strategy specifically for DO applicants
• How to compensate for lower scores and showcase your strengths
• How to build and execute a realistic program list
• Concrete examples and timelines tailored to DO graduates

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How Internal Medicine Programs View DO, COMLEX, and USMLE

DO vs MD in the Internal Medicine Residency Landscape

Internal medicine is among the most DO-friendly specialties. Many IM programs:

• Already have DO residents and faculty
• Understand COMLEX scoring
• Actively recruit DO students, especially community and university-affiliated community programs

However, there are tiers:

1. Highly DO-friendly community and safety-net programs
2. Mid-tier university-affiliated programs with mixed MD/DO residents
3. Highly competitive academic/university programs that may be more selective and historically MD-heavy

Your Step and COMLEX scores influence which tier is realistic—but they are not the only factor.

COMLEX vs USMLE: What Matters for IM

As a DO graduate, you might have:

• COMLEX only
• COMLEX + USMLE
• Lower USMLE scores but solid COMLEX
• A failed Step attempt with a later pass

General Patterns in IM Programs

• Many IM programs accept COMLEX-only applicants, especially community and DO-friendly university programs.
• Some academic programs:
  • Prefer or require USMLE Step scores.
  • Use Step 2 CK as a primary comparison metric.
• For programs that accept COMLEX only, they may:
  • Use internal conversion tables or
  • Evaluate your performance in the context of your school and entire application.

If you already have USMLE scores, you cannot hide them; they will be seen in ERAS. If you do not, you must decide whether taking Step 2 CK (beyond COMLEX) will help your competitiveness and broaden the number of programs you can target.

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Step 1 Strategy for DO Graduates in IM

Even though Step 1 is now Pass/Fail, it still influences how program directors perceive risk. For DOs, the context of your pass and the relationship to COMLEX performance matter.

Scenario 1: First-Time Step 1 Pass (No Failures)

If you passed Step 1 on the first attempt:

• Programs see this as a basic threshold of reliability.
• Your Step 2 CK strategy becomes the primary way to distinguish yourself.
• For DOs who took both:
  • Solid COMLEX Level 1 + Step 1 pass = stable academic foundation.

What to emphasize:

• Consistency: “Steady academic performance across pre-clinical years”
• Upward trajectory: Use strong clerkship grades and Level 2/Step 2 CK to show growth.

Scenario 2: Step 1 Failure Before Pass

If you failed Step 1 and then passed:

• This is a red flag, but not fatal—especially in internal medicine.
• Programs will ask:
  • Was the failure followed by clear improvement?
  • Did the applicant learn and adjust?
  • Are there other indicators of success (COMLEX, Step 2, clinical performance)?

Your strategy:

• Crush Step 2 CK and COMLEX Level 2-CE.
• Show evidence of course/clerkship improvement after the failure.
• Address the failure in your personal statement or MSPE only if needed, framing it as:
  • A lesson in study strategy and resilience.
  • A turning point that led to better habits and stronger performance.

For a DO graduate with a prior Step 1 fail, matching in internal medicine is still very attainable, especially for DO-friendly and community programs, if Step 2 CK and Level 2 are strong.

Scenario 3: COMLEX-Only, No USMLE Step 1

If you did not take USMLE Step 1:

• Many IM programs are fine with this, especially DO-heavy ones.
• You will be evaluated heavily on COMLEX scores and Step 2/Level 2 performance.
• Your program list must be tailored to programs explicitly stating they accept COMLEX-only applicants.

Here, your Step 2 CK decision becomes strategic: if you want to compete for more academic or university programs, taking Step 2 CK may be very helpful.

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Step 2 CK and COMLEX Level 2-CE: Your Primary Weapon in IM

For an internal medicine residency application, Step 2 CK and COMLEX Level 2-CE carry major weight, often more than Step 1. This is especially critical for:

• DO graduates who feel they have a low Step score match risk
• Anyone with a Step 1 fail or borderline performance
• COMLEX-only applicants wanting to broaden their program pool

What Is a “Good” Step 2 CK for IM?

IM programs vary widely, but as general ballparks (these are not absolute cutoffs):

• Competitive academic IM programs: Step 2 CK often in the mid–250s+ range for MDs; DOs may match successfully with 245–255+ plus strong overall profile.
• Solid university-affiliated/community hybrid IM programs: Successful DOs commonly match with 235–250.
• Community, safety-net, and DO-heavy IM programs: Applicants often match with 220–235, particularly when other aspects of the application are strong.

If you are targeting DO graduate residency opportunities in internal medicine, your goal should be:

• At least around national average (or above) on Step 2 CK
• Strong relative performance on COMLEX Level 2-CE (ideally at or above the mean)

Low Step Score Match Strategy for DO Graduates

If your Step 1 or early COMLEX scores are not where you hoped, Step 2 CK and Level 2 are your second chance.

A rough framework:

• Step 1 Pass with marginal performance (or fail, then pass)
  → Aim for Step 2 CK ≥ 235 and a clearly stronger COMLEX Level 2.
• No USMLE, COMLEX Level 1 slightly below average
  → Aim for COMLEX Level 2 at or above the mean, and consider Step 2 CK if you want broader program options.
• Already have a low Step 2 CK (e.g., low 220s or below)
  → You must overcompensate through:
  • Strong letters of recommendation (especially from IM faculty)
  • Excellent clinical performance and sub-internships
  • A targeted, broad program list with many DO-friendly and community programs
  • A compelling personal story and clear fit for internal medicine

Timing Strategy: When to Take Step 2 CK

For DO graduates, the Step 2 CK strategy is tightly linked to timing:

• Best case: Take Step 2 CK early enough that your score is available by the time you apply through ERAS (September).
• This allows:
  • Programs to see your improvement beyond Step 1.
  • You to highlight a strong Step 2 score to offset earlier concerns.

If you are at risk for a weak Step 2 score, consider:

• Taking it slightly later to maximize prep time—but not so late that your score is missing on most applications.
• If you feel underprepared close to your test date:
  • Discuss with your dean/advisor about delaying the exam if realistic.
  • Use NBME and COMSAE practice exams to make data-driven decisions.

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Building a Step Score–Centered Application Strategy for IM

Your Step and COMLEX scores are just one axis of your overall application. To maximize your IM match odds, especially as a DO graduate, you need a coherent, realistic strategy.

1. Understand Your Score Profile in Context

Create a concise “score snapshot”:

• Step 1: Pass / fail and context (first attempt? timing?)
• COMLEX Level 1: Score percentile relative to peers
• Step 2 CK: Score and comparison to national mean
• COMLEX Level 2-CE: Score and trajectory vs Level 1

Interpretation examples:

• Profile A (Strength):

  • Step 1: Pass (first attempt)
  • COMLEX L1: Slightly below mean
  • Step 2 CK: 244
  • COMLEX L2: At or slightly above mean
    → Narrative: “Improving trajectory, strong clinical knowledge, ready for IM.”

• Profile B (Recovery):

  • Step 1: Fail, then Pass
  • COMLEX L1: Below mean
  • Step 2 CK: 235
  • COMLEX L2: Above mean
    → Narrative: “Initial struggles, then strong recovery; now performing well in clinically oriented exams.”

• Profile C (COMLEX-only, average):

  • COMLEX L1: At mean
  • COMLEX L2: Slightly above mean
  • No USMLE
    → Narrative: “Consistent performance and strength on osteopathic exams; focus on DO-friendly IM programs.”

2. Match Your Profile to Target Program Types

Think about program types in tiers, then align your application volume:

• Reach Programs (10–20%)

  • University-based, research-heavy, more Step-focused
  • More realistic if Step 2 CK and Level 2 are clearly strong

• Target Programs (40–60%)

  • University-affiliated and strong community IM programs
  • DO-friendly, used to COMLEX interpretation
  • Moderate Step expectations (not ultra-competitive)

• Safety Programs (30–40%)

  • Community, DO-heavy, and smaller hospital-based programs
  • Historically match a significant number of DO graduates

For a DO graduate with Step scores on the lower side:

• Aim for a larger number of safety and DO-friendly programs.
• Apply broadly (often 60–100+ IM programs, depending on how low the scores and other risk factors are).

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Compensating for Lower Step Scores as a DO Applicant

If you are worried about a low Step score match outcome, your mission is to make everything else in your application so strong that programs view you as a safe, motivated, and collegial intern—even if your test scores are not ideal.

1. Maximize Clinical Performance and Sub-Internships

Internal medicine program directors value:

• Strong IM clerkship grades (Honors/High Pass)
• Sub-internships or acting internships in medicine
• Evidence that you can function well on the wards

Actionable steps:

• Prioritize your third- and fourth-year IM rotations:
  • Be early, present, and proactive.
  • Take ownership of patients within your scope.
  • Ask for feedback and act on it.
• Do at least one sub-internship in internal medicine, ideally:
  • At your home institution or
  • At a DO-friendly IM program where you might apply.

Strong clinical performance can help offset less competitive Step scores, especially in community or DO-friendly programs.

2. Secure Strong, Personalized Letters of Recommendation

With borderline or low Step scores, letters of recommendation (LORs) from internal medicine faculty become critical.

Priorities:

• At least:
  • One letter from an IM clerkship or sub-I director
  • One from an IM faculty who supervised you closely
  • Optional: additional letter from research, leadership, or another core specialty
• Request letters from attendings who:
  • Know you well enough to describe specific patient care examples
  • Can vouch for your work ethic, teachability, communication, and professionalism

Tips:

• Ask directly: “Do you feel you can write me a strong letter of recommendation for internal medicine?”
• Provide them with:
  • Your CV
  • A short summary of your goals in IM
  • Any unique circumstances (e.g., early academic struggles and later improvement) so they can contextualize your trajectory.

3. Use Your Personal Statement Strategically

Your personal statement for internal medicine is a chance to:

• Show maturity and insight.
• Affirm your fit for IM: intellectual curiosity, continuity, complexity, teamwork.

If you have Step or COMLEX issues (low scores, a fail):

• You may briefly acknowledge them, but avoid over-focusing.
• Emphasize what you learned:
  • “I learned how to adapt my study strategies, seek help early, and build sustainable habits.”
• Then pivot to:
  • Your clinical strengths
  • The type of resident and colleague you will be
  • Your long-term goals in IM (e.g., primary care, hospitalist, fellowship)

Do NOT:

• Make excuses or blame others.
• Write a Step-score-centered statement; your scores are part of the story, not the entire story.

4. Show Consistency Through Your CV and Activities

Internal medicine values reliability, compassion, and intellectual engagement. You can demonstrate this through:

• Longitudinal clinical volunteering (free clinics, underserved care)
• Teaching or tutoring (especially for medical students or pre-meds)
• Quality improvement (QI) projects or simple research contributions in IM
• Leadership roles in osteopathic or internal medicine organizations

These elements are especially important when your numeric scores are not your strongest area; they help programs visualize you as a complete, reliable colleague.

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Crafting a Timeline and Execution Plan

Here is a practical, high-yield timeline for a DO graduate aiming for internal medicine, with an emphasis on Step score strategy.

Third Year (Core Clinical Year)

• Early-Mid 3rd Year

  • Start building relationships with IM faculty.
  • Take your internal medicine core clerkship seriously—aim for Honors and strong narrative comments.
  • Begin light Step 2 CK and COMLEX Level 2 preparation.

• Late 3rd Year

  • Take COMLEX Level 2-CE and Step 2 CK (if planning to do USMLE) between late 3rd and early 4th year, allowing:
    • Time for retake if disaster
    • Scores to be available for ERAS
  • Use NBME/COMSAE practice scores to determine if you’re close to your target.

Early Fourth Year (Before ERAS Submission)

• Complete at least one sub-internship in internal medicine.
• Finalize your list of IM programs:
  • Identify DO-friendly and COMLEX-accepting programs.
  • Separate into reach/target/safety.
• Request letters of recommendation from IM faculty.
• Craft your personal statement with a clear IM focus and coherent story.

ERAS Application and Interview Season

• Submit ERAS as close to opening as possible (September).
• Make sure all Step and COMLEX scores are released.
• During interviews:
  • Be prepared to discuss your Step/COMLEX trajectory honestly but concisely.
  • Keep the focus on your strengths: clinical performance, patient care, collaboration.

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Frequently Asked Questions (FAQ)

1. As a DO graduate, do I need to take USMLE Step 2 CK if I already have COMLEX scores?

You don’t always need Step 2 CK, but it can be strategically valuable:

• You generally should take Step 2 CK if:
  • You want to apply to university or research-heavy IM programs that historically prefer USMLE.
  • Your COMLEX Level 1 was weaker, and you believe you can significantly outperform that on Step 2 CK.
• You may choose COMLEX-only if:
  • Your school and advisors confirm that your target list is largely DO-friendly and COMLEX-accepting.
  • Your COMLEX Level 1 and 2 scores are solid and your practice USMLE exams suggest only modest advantage.

Discuss with your dean or advisor, and examine specific programs’ websites for USMLE vs COMLEX requirements.

2. Can I still match internal medicine with a low Step score or a Step 1 failure as a DO?

Yes, you can still match IM, especially with a thoughtful strategy:

• Internal medicine is broader and more DO-friendly than many other specialties.
• A Step 1 failure can be overcome with:
  • A strong Step 2 CK and COMLEX Level 2 performance
  • Solid clinical grades and supportive letters
  • A realistic and broad program list emphasizing DO-friendly and community programs
• Many program directors are more interested in:
  • Whether you learned from setbacks
  • Your current level of performance and reliability
  • Your clinical demeanor and teamwork

You will need to be proactive and broader in your application strategy, but a match is very attainable.

3. How many internal medicine programs should I apply to if I have low Step scores as a DO?

There is no perfect number, but as a general guideline:

• With borderline or low scores, consider applying to:
  • 60–100+ internal medicine programs, depending on how low the scores and whether there are other red flags (gaps, fails, etc.).
• Ensure:
  • A high proportion of DO-friendly and community programs
  • Several safety options in locations where competition is lower
• Quality matters too:
  • Tailor your application and personal statement to internal medicine.
  • Highlight any strong regional ties to areas where you are applying.

4. Should I delay my Step 2 CK to study more if my practice scores are low?

Delaying can be helpful if:

• Your NBME practice exams consistently show scores well below your target.
• You realistically have the time and resources to improve your knowledge and test-taking.

However, be cautious:

• Taking Step 2 CK too late can mean your score is missing when you apply, which hurts your competitiveness.
• For many DO graduates, having a solid (even if not stellar) Step 2 CK score on time is better than a slightly higher score that arrives after interview offers are decided.

Work with a trusted advisor, look at objective data (practice test trends), and balance score potential with timing requirements.

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By approaching your Step and COMLEX scores with a deliberate strategy, matching your program list to your profile, and strengthening every other element of your application, you can significantly increase your chances of matching into a strong internal medicine residency as a DO graduate—even if your scores aren’t perfect.