Strategies for DO Graduates with Low Step Scores in Medical Genetics Residency

Understanding Your Situation as a DO Graduate With a Low Step Score

As a DO graduate interested in medical genetics, you may worry that a low Step 1 score or below average board scores will close doors. In reality, the genetics match is still attainable with careful planning, strategic program selection, and deliberate skill-building.

Key realities to anchor you:

• Medical genetics is a small, niche specialty with a limited number of applicants compared with larger fields like internal medicine or general surgery.
• Programs often care deeply about:
  • Genuine interest in genetics
  • Longitudinal commitment to the field
  • Maturity, professionalism, and communication skills
• As a DO graduate, you may face:
  • Less automatic familiarity from program directors vs MDs
  • Bias in some academic centers (varies widely)
  • Extra need to demonstrate strong clinical reasoning and academic capability

Your low Step 1 score or weaker COMLEX performance is a meaningful data point—but it is only one data point. You can build an application that shifts the conversation from scores to strengths and clear “fit” for medical genetics.

This article focuses on actionable strategies for a DO graduate with low scores who wants to match into a medical genetics residency, including combined programs like pediatrics–medical genetics or internal medicine–medical genetics.

---

How Medical Genetics Training Pathways Affect Your Strategy

Before discussing tactics for matching with low scores, it’s essential to understand how genetics residency training is structured, because your most practical path may not be a “straight” medical genetics residency.

Core Training Pathways

In the U.S., medical genetics training commonly happens via:

1. Combined Programs (Most Common Route)

   • Pediatrics–Medical Genetics (Peds/Genetics): 4–5 years combined
   • Internal Medicine–Medical Genetics (Med/Genetics): 4–5 years combined
   • Some institutions also offer combinations with maternal-fetal medicine or other subspecialties, but these are less common as entry pathways.

2. Categorical Medical Genetics (Less Common for a New Graduate)

   • Adult or clinical genetics programs (often 2-year) requiring a prior primary residency in:
     • Pediatrics
     • Internal medicine
     • OB/GYN
     • Or another relevant primary specialty

For many DO graduates with below average board scores, the most realistic strategy is:

• Step 1: Match into an ACGME-accredited primary specialty that is genetics-friendly (often pediatrics or internal medicine).
• Step 2: Build a strong genetics portfolio during residency.
• Step 3: Match into a medical genetics residency or fellowship later.

This two-step route is not “settling.” In fact:

• Many genetics faculty originally trained in peds or IM.
• You’ll be a stronger geneticist with solid primary clinical skills.

However, some DO graduates still successfully match directly into combined peds-genetics or med-genetics even with low scores, especially if they’ve built a very strong genetics-focused application.

Why This Matters for Low Scores

Programs in small, niche fields like genetics often:

• Place significant weight on fit, maturity, and communication.
• Look for applicants who understand the breadth of genetics (pediatrics, adult medicine, cancer, metabolic, prenatal).
• Value reliable long-term interest more than a single exam score.

For a DO graduate, this means your strategy matters more than your score alone. You may need to:

• Cast a wider net—including primary specialties plus combined programs.
• Be willing to match into a stepping-stone residency and then pivot to genetics.
• Build a genetics identity through selectives, research, advocacy, and electives, even if your official specialty label is “pediatrics” or “internal medicine.”

---

Reframing and Managing a Low Step 1 or Below Average Board Scores

You cannot change your existing Step or COMLEX scores—but you can control how they are perceived and whether they define your entire application.

1. Analyze the Numbers Objectively

Ask yourself:

• Is your Step 1 score low but Step 2 CK is significantly higher?
  • This suggests growth and resilience—very important to program directors.
• Are your COMLEX scores stronger than your USMLE scores?
  • Some programs will weigh COMLEX more for DO graduates.
• Are the scores consistently low, or a single outlier (e.g., one especially bad exam)?

Use this reflection to guide how you explain your performance and what strengths to highlight.

2. Create a Clear Redemptive Academic Story

Program directors know that tests are imperfect measures. What they want to see:

• Have you improved over time?
• Have you learned from setbacks?
• Can you perform clinically in demanding rotations?

You can help them see this by:

• Excelling on Step 2 CK or COMLEX Level 2

  • If you haven’t taken Step 2 yet, devote extra time to structured studying.
  • Consider a dedicated 6–8 week plan, with NBME practice exams and COMSAEs.
  • The combination “low Step 1 score, strong Step 2 CK” strongly reassures programs.

• Honest but concise explanation (in ERAS or during interviews):
  Example framing:

  “My Step 1 performance did not reflect my actual clinical capabilities. I recognized gaps in my test-taking approach and used that experience to restructure my study methods. Since then, I’ve implemented spaced repetition, group review, and regular self-assessment, which contributed to significantly improved performance on subsequent exams and stronger clinical evaluations.”

Avoid overexplaining or being defensive. Acknowledge it, describe your adjustment, move on to your strengths.

3. Maximize Non-Test Evidence of Competence

To counterbalance a low Step 1 score or below average board scores:

• Honors or strong grades in core rotations (especially:

  • Pediatrics
  • Internal medicine
  • OB/GYN
    These all overlap heavily with genetic medicine.)

• Outstanding clinical evaluations that emphasize:

  • Critical thinking
  • Reliability
  • Communication with patients and families
  • Teamwork and professionalism

• Sub-internships / acting internships in:

  • Pediatrics (especially NICU, general peds, or peds subspecialty)
  • Internal medicine (hospitalist, oncology, rheumatology)
  • Any rotation with genetics or metabolic components if available

Aim to have letters explicitly address concerns about test scores:

“Although [Applicant]’s earlier test scores were not as strong as they hoped, their clinical performance has consistently been among the top tier of students I have worked with, with excellent diagnostic reasoning and reliability in caring for complex patients.”

Letters like this shift focus from the numbers to your day-to-day performance.

---

Building a Strong Medical Genetics Identity as a DO Graduate

To stand out in the osteopathic residency match and later in the genetics match, you must show that genetics is not a last-minute choice but a sustained interest.

1. Immerse Yourself in Genetics-Related Experiences

Think broadly. Genetics is everywhere in medicine.

Practical ways to build a genetics portfolio:

• Electives in genetics:
  • Clinical genetics consult service
  • Cancer genetics clinic
  • Metabolic genetics or biochemical genetics clinic
  • Prenatal diagnosis / MFM genetics
• Related specialties:
  • Pediatric neurology (neurogenetics)
  • Hematology/oncology (cancer genetics, hereditary syndromes)
  • Endocrinology (genetic syndromes, disorders of growth and puberty)

If your school lacks a genetics department, you can:

• Arrange away rotations at institutions with established genetics programs.
• Seek virtual electives or tele-genetics experiences when available.

2. Targeted Research and Scholarly Activity

You do not need a PhD in genetics to be competitive, but having some scholarly work in a genetics-adjacent area significantly reinforces your story.

Possibilities include:

• Case reports involving:
  • Rare genetic syndromes
  • Metabolic disorders
  • Inherited cancer syndromes
  • Skeletal dysplasias, neurocutaneous disorders, etc.
• Quality improvement projects:
  • Improving genetic testing workflows
  • Enhancing family history documentation
  • Standardizing metabolic screening protocols
• Retrospective chart reviews or small observational projects:
  • Outcomes for patients with specific chromosomal abnormalities
  • Utility of genetic counseling in NICU or oncology patients

If you’re a DO graduate from a school without heavy research infrastructure:

• Contact clinical genetics or peds/IM faculty at nearby institutions and offer help with ongoing projects.
• Ask explicitly:

  “I’m a DO graduate interested in a future medical genetics residency. I have limited research experience but strong follow-through and writing skills. Are there any small projects or case reports I could join to start building experience in this field?”

Even one or two well-constructed abstracts or posters can make a big difference.

3. Membership and Leadership in Genetics Organizations

Show ongoing engagement beyond coursework:

• Join American College of Medical Genetics and Genomics (ACMG) as a trainee (student/early career membership).
• Attend virtual or in-person ACMG or ASHG (American Society of Human Genetics) conferences when possible.
• Participate in:
  • Genetics journal clubs
  • Genetics interest groups or specialty interest clubs at your medical school
• If none exist at your institution:
  • Start a Genomics in Medicine Interest Group and invite genetics faculty (even virtually) to speak.
  • Organize a case-based session on hereditary cancer or metabolic emergencies.

Leadership roles like these can be highlighted in ERAS and interviews and help show your commitment despite low scores.

4. Showcase Osteopathic Strengths in a Genetics Context

As a DO graduate, leverage what sets you apart:

• Holistic, patient-centered care—a perfect fit for families facing lifelong genetic conditions.
• Emphasis on communication and whole-person care, essential in genetic counseling settings.
• Training in longitudinal, primary care perspectives, which complement genetics’ chronic disease focus.

In your personal statement and interviews, connect your osteopathic background to genetics:

“My osteopathic training emphasizes treating the whole person and understanding how biological, emotional, and social factors intersect. In genetics, these principles are critical when supporting families facing chronic, inherited conditions with implications across generations.”

---

Application Strategy: Program Selection, Personal Statement, and Letters

With a low Step score and DO background, your application strategy matters as much as your raw metrics.

1. Choosing Programs Strategically

You’ll likely need a two-pronged approach:

1. Primary Specialty Programs that keep the door open to genetics:

   • Pediatrics (especially academic or children’s hospitals)
   • Internal medicine with strong subspecialty and genetics exposure

2. Combined or Genetics-Oriented Programs, such as:

   • Med–Genetics or Peds–Genetics combined programs
   • Pediatric residencies with dedicated genetics tracks or strong genetics departments

When researching programs:

• Look for:

  • Evidence of DO-friendly culture (past DO residents, inclusive language)
  • Strong genetics or genomics departments or affiliated children’s hospitals
  • Faculty profiles showing clinical genetics or physician-scientists in genomics

• Review:

  • Program websites for references to human genetics, personalized medicine, or precision medicine
  • Publications from faculty in genetics or genomics

Consider applying broadly:

• A mix of:
  • Community-based pediatrics/IM programs where your low Step 1 score is less critical
  • Mid-tier academic programs with some genetics presence
  • Select higher-tier programs if you have strong non-score assets (research, strong letters, unique life experiences)

2. Crafting a Compelling Personal Statement

For DO graduates with low scores who want medical genetics:

• Be explicit about your long-term goal: a medical genetics residency or combined program.

• Tell a coherent story:

  • How you discovered genetics (patient interaction, research, personal/family experience).
  • What aspects of genetics resonate with you:
    • Complex diagnostics
    • Counseling families
    • Systems-level medicine
  • How your DO training shaped your approach.

• Address low scores indirectly:

  • Do not lead with them.
  • If needed, include a brief, matter-of-fact explanation:

    “Earlier in my training I struggled to translate knowledge into standardized exams, which is reflected in my Step 1 score. In response, I revised my study methods and sought frequent feedback, contributing to stronger clinical evaluations and an upward trend in subsequent assessments.”

• End with a clear vision:

  • Interest in working at the intersection of clinical care, genomics, and patient advocacy.
  • Desire to contribute to multidisciplinary teams managing rare and complex conditions.

3. Securing Strong Letters of Recommendation

Your letters must override the signal of your low Step 1 or COMLEX scores.

Aim for:

• At least one letter from:
  • A genetics faculty member (ideal), or
  • A subspecialist with heavy genetics overlap (oncology, neurology, MFM, metabolic).
• Additional letters from:
  • Pediatrics or IM faculty who supervised you in demanding rotations.
  • Research mentors, if you have genetics-related projects.

Coach your letter writers (politely) about your goals:

• Share:
  • A CV and personal statement draft.
  • Your long-term goal in medical genetics.
  • The fact that your board scores are lower than ideal, and that you are hoping they can speak to your clinical competence, reliability, and analytical thinking.

When a letter says:

“I am aware that [Applicant]’s standardized test performance does not fully reflect their clinical ability. In my service, they consistently displayed strong diagnostic reasoning with complex patients, quickly integrating genetic and metabolic considerations into workups. I would be happy to have them as a resident.”

…it makes your low Step 1 score far less damaging.

---

Interviewing, Signaling Interest, and Backup Planning

Once you secure interviews, your performance there can overcome the initial negative impression from your scores.

1. Excelling in Interviews as a DO Candidate With Low Scores

Key goals:

• Demonstrate:
  • Maturity about your academic history
  • Insight into the field of genetics
  • Ability to connect with families and colleagues
  • Commitment to a career in genetics, not just “any residency spot”

Common interview themes for genetics-oriented applicants:

• “Tell me how you became interested in medical genetics.”
• “What role do you see genetics playing in everyday medicine?”
• “How would you counsel a family if you had to deliver difficult genetic news?”
• “You mentioned a low Step 1 score—what happened and what changed since then?”

Prepare structured responses:

• Use specific cases:
  • A child with a suspected metabolic condition
  • A family with multiple relatives with cancer
  • A NICU patient with congenital anomalies
• Show:
  • You understand basic principles of inheritance, testing, and counseling.
  • You respect the limits of knowledge (genetic variants of uncertain significance, evolving evidence).

When addressing low scores, keep it short and forward-looking:

• Recognize the issue
• Express what you learned
• Highlight your growth and current performance

2. Signaling and Demonstrating Program-Specific Interest

For medical genetics or combined programs, faculty want to avoid selecting residents who might leave early or are unsure.

You can stand out by:

• Sending polite, concise emails:
  • Before or after interviews, expressing specific things you appreciate about their genetics training.
• Referencing:
  • Particular clinics or rotations (e.g., metabolic clinic, cancer genetics clinic).
  • Faculty research you’ve read.
• Providing:
  • An updated CV with any newly accepted abstract/poster.
  • Mention if you’re planning an elective with their genetics department (if possible).

Programs often remember applicants who show authentic, informed interest even if their scores are weaker.

3. Thoughtful Backup Plans That Keep Genetics on the Table

Backup planning is not a sign of failure; it’s good strategy.

If you don’t match directly into a combined medical genetics program, you can still reach your goal by:

• Matching into a solid pediatrics or internal medicine residency that:
  • Has genetics exposure
  • Is DO-friendly
  • Allows electives in genetics or genomics

During residency:

• Seek out every genetics rotation or consult opportunity.
• Join or start a genetics journal club.
• Attend ACMG or other genetics conferences.
• Build relationships with local or regional geneticists.

Afterward:

• Apply to a medical genetics residency or clinical genetics fellowship with:
  • Real-world, post-graduate clinical experience
  • A stronger set of letters from attending physicians
  • A more genetics-focused CV

Many practicing geneticists took the route of primary specialty → genetics training—and for a DO graduate with low Step 1 score, it may be your strongest long-term path.

---

FAQs: Low Step Score Strategies for DO Graduates in Medical Genetics

1. Can I realistically match into a medical genetics residency with a low Step 1 score as a DO graduate?

Yes, it’s possible—but usually requires extra strategy. Many medical genetics physicians trained first in pediatrics or internal medicine. As a DO with low Step 1 or below average board scores, your best chance is often:

• Matching into a DO-friendly peds or IM program (or a combined program if you’re competitive in other ways).
• Building a strong genetics portfolio during residency.
• Then applying for a medical genetics residency or fellowship afterward.

Direct entry into combined med-genetics or peds-genetics is also possible if you can demonstrate a clear upward trend (e.g., strong Step 2 CK), robust genetics involvement, and strong letters.

2. Should I still take USMLE Step 2 if my Step 1 score is low and I’m a DO?

If you already took Step 1 and scored low, a strong Step 2 CK score can substantially help mitigate concerns. Many program directors value Step 2 more because it’s more clinically oriented. As a DO, you’ll also have COMLEX scores, but a competitive Step 2 CK often helps you be evaluated on equal footing with MD applicants, especially at academic programs.

3. What types of programs are more DO-friendly for someone like me?

In the context of the osteopathic residency match and later the genetics match:

• Community-based and mid-tier academic pediatrics and internal medicine programs often:
  • Are more flexible regarding low Step scores
  • Have a track record of training DO residents successfully
• University-based programs with a mission around primary care, underserved care, or holistic training may be more open to DOs.
• For genetics specifically, look for:
  • Programs whose current residents or alumni include DOs.
  • Faculty who trained at osteopathic institutions or explicitly mention DOs in recruitment materials.

4. How can I prove I’m serious about a future in medical genetics?

You can demonstrate seriousness through:

• Consistent exposure:
  • Genetics or genomics electives
  • Genetics consults or clinics
  • Related subspecialty rotations (oncology, neurology, MFM, metabolic)
• Scholarly work:
  • Case reports on genetic or metabolic disorders
  • QI or research projects in genetics-related areas
• Professional involvement:
  • Membership in ACMG or related societies
  • Attendance at genetics conferences or webinars
• Letters and personal statement that:
  • Clearly articulate your long-term plan to pursue a medical genetics residency
  • Show that mentors in the field recognize your interest and potential

Over time, this consistent trajectory will matter more to selection committees than a single low Step 1 score.

---

By understanding the structure of medical genetics training, building a compelling genetics identity, and strategically targeting DO-friendly and genetics-supportive programs, you can absolutely pursue a career in medical genetics—even with low Step scores. Your challenge is real, but with a plan, persistence, and a focus on your strengths, the medical genetics residency path remains open.