Strategic Guide for DO Graduates with Low Step Scores in Vascular Surgery Residency

Understanding the Challenge: Low Scores as a DO Applicant to Vascular Surgery

Vascular surgery is one of the more competitive surgical fields, and entering as a DO graduate with a low Step 1 score or below average board scores can feel daunting. The transition to pass/fail Step 1 has shifted emphasis toward Step 2 CK, clinical performance, research, and holistic review—but USMLE/COMLEX scores still matter, especially in an integrated vascular program.

As a DO graduate, you’re often balancing two challenges at once:

1. The osteopathic residency match curve: historically fewer DOs in vascular surgery compared with other specialties, and
2. The perception of risk around matching with low scores, especially for a high-acuity, procedure-heavy field.

Yet every cycle, applicants with imperfections—and yes, low scores—match into vascular surgery. They do it by being strategic, realistic, and relentlessly proactive.

This article will walk through detailed, actionable strategies tailored to a DO graduate with low Step scores who is aiming for an integrated vascular surgery residency or a general surgery route followed by vascular fellowship.

We’ll cover:

• How to frame and mitigate a low Step 1 score or low Step 2 CK
• Whether and how to retake exams or add Step 3
• Application strategies specific to DO graduates
• How to use rotations, research, and networking to offset scores
• When to consider alternative pathways (e.g., general surgery first)

Throughout, assume “low” means:

• Step 1: below passing pre-P/F era or now a pass with a known marginal performance
• Step 2 CK: < 230–235 for a highly competitive surgical subspecialty (exact thresholds vary)
• COMLEX: scores below the typical mean for matched applicants in surgical specialties

Your specific situation will differ, but the principles stay the same.

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Step Scores Reality Check: What “Low” Means in Vascular Surgery

Before crafting a plan, you need an accurate understanding of where you stand and how programs interpret your scores.

How Programs View Scores in an Integrated Vascular Program

Most integrated vascular surgery residencies receive far more applications than interview slots. Scores are often used as initial filters for:

• USMLE Step 2 CK
• COMLEX Level 2-CE (if they accept COMLEX)
• Step 1 (if available) or COMLEX Level 1 (even if P/F, they may still review the transcript)

Typical patterns:

• Highly academic, brand-name programs may favor Step 2 CK ≥ 240–245 and often prefer or require USMLE scores even for DOs.
• Mid-tier or newer programs may be more flexible with scores but look heavily at clinical performance, letters, and perceived commitment to vascular surgery.
• Community or hybrid programs may prioritize work ethic, fit, and strong letters over pure numbers, but still must ensure you can pass boards.

If your Step scores are below the median for vascular surgery match data, it doesn’t automatically exclude you, but it does mean:

• Fewer auto-screen passes (especially without USMLE)
• Higher pressure to demonstrate strength in every other domain
• Need for a much more targeted application strategy

Impact of a Low Step 1 Score vs. Low Step 2 CK

For DO graduates, Step 2 CK is often more critical in the osteopathic residency match for competitive surgical fields:

• Low Step 1, stronger Step 2 CK: This is much easier to recover from. Programs can interpret this as growth, improved preparation, and resilience.
• Average Step 1, low Step 2 CK: More concerning, because Step 2 CK is more predictive of board passage and clinical readiness.
• Low COMLEX but no USMLE: Some vascular surgery residency programs struggle to interpret COMLEX percentiles/levels compared with USMLE; this can place you at a disadvantage if they primarily use USMLE-based filters.

Your strategy will differ depending on which of these applies to you.

Be Honest, Not Hopeless

You need a realistic but not defeatist appraisal:

• Compare your scores to:
  • NRMP Charting Outcomes (MD) for vascular surgery
  • AOA/ERAS reports for DO performance in surgical specialties
• Talk to:
  • A vascular surgery mentor
  • A surgery program director or advisor at your COM
  • Residents who recently matched vascular (especially DOs)

Use this data to decide between:

• Directly targeting integrated vascular surgery residency, or
• Pursuing categorical general surgery with a plan for vascular fellowship (which may be far more attainable with low scores, and still leads to the same career).

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Strategic Moves to Offset Low Step Scores

Once you know where you stand, your next step is to build compensatory strengths that can outweigh below average board scores.

1. Maximize Step 2 CK (and COMLEX Level 2-CE)

If you have not taken Step 2 CK or COMLEX Level 2 yet, your score here is your single biggest opportunity to change your application trajectory.

Action plan:

• Treat Step 2 CK like a second chance at Step 1
  • Aim to outperform your Step 1 by a noticeable margin.
  • For example: 210 → 235 or 220 → 245+ tells a story of growth.
• Use:
  • NBME practice exams and UWorld self-assessments
  • COMSAE/COMVEX for Level 2-CE calibration
• Delay if:
  • You’re consistently scoring below your target range on practice tests
  • A few extra weeks would realistically raise your score

If you already have a low Step 2 CK:

• Strong upward COMLEX Level 2-CE (if Step 2 is low but COMLEX is high) can help somewhat, but many vascular programs weigh Step 2 CK more.
• You should double down on clinical performance, letters, and research (discussed below).

2. Consider Taking USMLE as a DO (If You Haven’t)

For a DO graduate targeting a competitive surgical field, not having USMLE can be an additional obstacle—even if not explicitly stated:

• Many integrated vascular programs use USMLE-based filters.
• They may accept COMLEX, but their internal comparison framework is USMLE-driven.

If you have only COMLEX and your scores are borderline:

• Consider taking Step 2 CK specifically (even if you skipped Step 1) if permitted by your timeline and state licensing rules.
• If your COMLEX Level 2-CE suggests you’re capable of a solid Step 2 CK performance, this can significantly improve your visibility.

If your COMLEX scores are already low, only take USMLE if:

• Practice test scores predict a meaningfully higher Step 2 CK result
• You have protected time to study
• You’re not close to application season

3. Use Step 3 Strategically (But Carefully)

A common question:
“Should I take Step 3 to offset my low Step scores?”

For a student applying directly from med school (DO or MD), Step 3 is often irrelevant at the application stage. But as a DO graduate (especially if reapplying or after a gap year), Step 3 can occasionally help when:

• Your Step 1/2 numbers are low, but you can demonstrate:
  • A significant improvement on Step 3, and
  • Proof you can pass higher-level exams on first attempt.

Cautions:

• A weak Step 3 score or failure further confirms program directors’ fears about board performance.
• Only take Step 3 if:
  • Practice exams predict comfortable passing
  • You can realistically do better than prior scores
  • You discuss the decision with a trusted PD or advisor first

4. Dominate Your Clinical Rotations and Sub-I’s

In vascular surgery, how you function on the team often matters more than your exact score number once you get past filters.

For a DO graduate with a low Step 1 score or low Step 2 CK, away rotations and Sub-I’s become your most powerful weapons.

Focus on:

• Core Surgery Rotation Performance

  • Aim for outstanding evals, honors if available, and strong narrative comments highlighting:
    • Work ethic
    • Technical progress
    • Teamwork and reliability

• Vascular Surgery Electives and Sub-Internships (Sub-I)

  • Prioritize rotations at:
    • Programs where DOs have previously matched
    • Programs with a history of accommodating COMLEX or holistic review
  • On these rotations:
    • Show up early, be prepared, stay late
    • Read about every case the night before
    • Volunteer for consults, wound checks, and call
    • Ask for feedback and act on it

Concrete strategy example:

If your Step 2 CK is 220, you might be auto-screened out at a top-10 integrated vascular program. But a mid-tier or newer program where you did a stellar, months-long rotation—earning a letter that says “top 5% student I’ve worked with in the last decade”—may look past your scores.

5. Get Targeted, High-Impact Letters of Recommendation

With low scores, your letters must be exceptional, not just “good.”

Aim for:

• At least two letters from vascular surgeons, including:
  • One from a rotation at your home institution (if available), and
  • One from an away rotation at a program you’d love to match at.
• One additional letter from:
  • General surgery faculty who know your clinical work well, or
  • A research mentor in vascular surgery.

Letters should explicitly address:

• Your technical potential in a surgical field
• Your ability to master complex procedures and concepts
• Objective comparison (e.g., “top 10% of students,” “would rank among my best residents”)
• Your resilience and growth if they’re aware of your below average board scores

Do not be afraid to ask directly whether they can write you a “strong and supportive letter for a vascular surgery residency application.” If they hesitate, ask someone else.

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Building a Vascular Identity: Research, Networking, and Program Targeting

Even with weak scores, you can make yourself the “obvious vascular person” in your application.

1. Invest in Vascular Surgery Research and Scholarly Output

Research is particularly valuable when scores are weak because it:

• Demonstrates academic potential beyond test performance
• Gives you sustained contact with vascular surgeons who can advocate for you
• Adds depth and specificity to your personal statement and interviews

Focus areas:

• Case reports of interesting vascular pathologies
• Retrospective database studies (e.g., outcomes in peripheral arterial disease)
• Quality improvement projects in vascular access, limb salvage, or post-op care
• Clinical reviews or educational pieces (even at your institution level)

Practical tips:

• If your home program lacks vascular surgery research:
  • Email nearby academic centers, especially those with DO-friendly reputations.
  • Offer to help with data collection, chart review, or literature reviews.
• Consider a dedicated research year if:
  • Your scores are significantly below norm for vascular surgery
  • You can join a reputable vascular lab or outcomes research group
  • You can reasonably expect multiple abstracts, presentations, or publications

2. Network Intentionally in the Vascular Surgery Community

Networking is not about favoritism; it’s about letting people see your work ethic and potential firsthand.

High-yield opportunities:

• SVS (Society for Vascular Surgery) conferences:
  • Present posters or abstracts if possible
  • Introduce yourself to program directors and faculty where you’re applying
• Regional vascular meetings:
  • Often smaller and more personal—easier to make real connections
• Virtual meet-and-greets or open houses:
  • Many integrated vascular programs host webinars to meet applicants
  • Ask thoughtful questions about training, DO graduates, and support for board prep (subtly highlighting your concern without oversharing your scores in group settings)

When you reach out by email:

• Attach a short CV (1–2 pages)
• Introduce yourself as:
  • A DO graduate highly committed to vascular surgery
  • Acknowledge you’re working to strengthen your application
• Politely inquire about:
  • Opportunities for observerships, research, or rotations
  • Their experience with DO graduates and COMLEX/USMLE

3. Targeting the Right Programs as a DO with Low Scores

Not every integrated vascular program is equally realistic with low scores. You should:

• Prioritize:

  • Programs with current or recent DO residents or fellows
  • Institutions that explicitly “accept COMLEX or DO applicants”
  • Newer or smaller integrated vascular programs that are still building their brand
  • Programs in less geographically competitive areas (e.g., away from coasts and large metro centers)

• Apply broadly:

  • If aiming directly for vascular surgery, consider applying to all programs where you meet basic thresholds, plus:
    • A large number of categorical general surgery programs as parallel or primary strategy
  • Rank programs honestly but strategically.

4. Consider the General Surgery–First Pathway

For many DO graduates with low Step scores, the most realistic and ultimately successful route to a vascular surgery career is:

1. Match into a strong categorical general surgery residency, then
2. Apply for a vascular surgery fellowship (5+2 pathway).

Advantages:

• General surgery programs (especially community or mid-tier university ones) are often more flexible about low Step scores than integrated vascular programs.
• Once you’re an excellent, board-passing surgery resident with strong vascular exposure, fellowship selection focuses more on:
  • Performance during residency
  • Letters from vascular attendings
  • Research and clinical achievements

You still become a board-certified vascular surgeon, with nearly identical scope of practice compared to integrated graduates.

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Application Execution: Crafting a Compelling Story Around Low Scores

You cannot hide your scores, but you can control the narrative around them.

1. Owning Your Low Scores in the Personal Statement (When Appropriate)

You do not need to lead with “I have a low Step 1 score.” However, it may be appropriate to briefly address scores when:

• There was a specific, time-limited circumstance (illness, family emergency, learning disability diagnosed later) that impacted your performance.
• Your subsequent record (Step 2, clerkships, research, work) clearly contradicts the implication that you’re a weak learner.

If you address it:

• Keep it brief and factual, not emotional or defensive.
• Emphasize:
  • What you learned
  • Concrete steps you took to improve
  • How your later performance (rotations, research, improved scores) demonstrates growth

Example framing (condensed):

“An acute family illness during my Step 1 preparation contributed to a score that does not reflect my capabilities. In response, I restructured my study approach, utilized practice-based feedback, and sought mentoring for advanced test-taking strategies. This process led to a [X]-point improvement on Step 2 and to honors in my surgery rotation. More importantly, it taught me how to adapt under pressure—an essential skill I now bring to the demanding environment of vascular surgery.”

2. Emphasize Strengths that Counterbalance Scores

Throughout your ERAS application, highlight:

• Hands-on procedural enthusiasm and skill development
• Outstanding clinical evaluations (especially in surgery, ICU, and vascular electives)
• Research productivity in vascular-related topics
• Longitudinal commitment (multiple years of involvement, not a last-minute pivot)

Program directors may forgive low numbers if they see evidence that:

• You’ve already been functioning at a high level in real clinical environments
• You are self-aware and coachable
• You have demonstrated resilience and growth over time

3. Prepare for Hard Questions in Interviews

You may be asked directly:

• “Can you explain your Step scores?”
• “How will you make sure you pass your boards on the first attempt?”

Prepare honest, concise answers:

• Own your performance without making excuses.
• Show:
  • Insight: You understand why it happened.
  • Action: You changed your methods (study strategies, scheduling, resource utilization).
  • Proof: Evidence of subsequent improvement or consistency (better exams, MCQs, rotation honors, Step 3, etc.).

Example response structure:

1. Acknowledge: “My Step 1 score was lower than I hoped…”
2. Brief reason (if relevant): “…in part because I underestimated the volume and didn’t use enough question-based learning.”
3. Adjustment: “For Step 2, I reorganized my schedule, completed two full passes of UWorld, and did weekly check-ins with a faculty mentor.”
4. Outcome: “I improved by X points and felt far more in control of the process, which mirrors how I now approach complex clinical problems.”

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Putting It All Together: Sample Roadmaps for Different Starting Points

To make this concrete, here are three example scenarios tailored to a DO graduate who wants vascular surgery but has low scores.

Scenario 1: DO Graduate, Low Step 1, Strong Step 2, Still in School

Profile:

• Step 1: Borderline or low pass
• Step 2 CK: 240+
• COMLEX: Around or above average
• Early vascular interest

Strategy:

1. Emphasize improvement trajectory in personal statement and interviews.
2. Secure at least two strong vascular surgery letters.
3. Pursue 1–2 vascular sub-I’s at DO-friendly integrated programs.
4. Apply to all integrated vascular programs plus a broad range of categorical general surgery positions.
5. Highlight research, leadership, and clinical excellence in application.

Scenario 2: DO Graduate, Low Step 1 and Low Step 2, Limited Research

Profile:

• Step 1: Low
• Step 2 CK: <230
• COMLEX: Below mean, no USMLE
• Currently MS4 or recent graduate

Strategy:

1. Focus on categorical general surgery as primary target, with vascular fellowship later.
2. If time allows, consider:
   • A dedicated vascular research year, ideally at a center with a vascular fellowship.
   • Taking USMLE Step 2 CK if practice tests show a realistic opportunity to markedly outperform COMLEX.
3. Use Sub-I’s in general surgery and vascular to obtain powerful letters.
4. Build a clear vascular identity through:
   • Case reports
   • QI projects
   • Conference presentations

Scenario 3: DO Graduate, Previous Non-Match in Integrated Vascular

Profile:

• Applied once to integrated vascular surgery with low scores; no match
• Year spent in preliminary surgery or research
• Still determined to pursue vascular

Strategy:

1. Meet with at least one program director (from any surgical program) to review your prior application.
2. Decide between:
   • Reapplying to integrated vascular (if feedback suggests you were close), or
   • Shifting fully toward categorical general surgery plus vascular fellowship.
3. Strengthen application with:
   • New or continued vascular research
   • Step 3 (if and only if strong practice scores)
   • Documented excellence in your current clinical role (prelim spot, research fellowship with clinical exposure)
4. If reapplying to integrated vascular, expand the list of programs significantly and still apply to general surgery as parallel path.

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FAQs: Low Step Score Strategies for DO Graduates in Vascular Surgery

1. Is it realistic to match directly into an integrated vascular surgery residency with low Step scores as a DO graduate?
It is possible but challenging. Most integrated vascular programs are small and competitive, with limited flexibility on test scores. If your scores are only slightly below average and you have strong Step 2 CK, excellent rotations, and powerful letters, you may still be competitive—especially at DO-friendly or newer programs. If your scores are substantially lower, your best long-term chance to become a vascular surgeon may be via a general surgery residency followed by vascular fellowship.

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2. As a DO, do I need USMLE scores for vascular surgery, or is COMLEX enough?
Many vascular surgery residency and fellowship programs say they “accept COMLEX,” but in practice, USMLE scores make it easier for programs to compare you directly to MD applicants and pass initial filters. If your COMLEX is borderline but practice tests suggest you could do well on Step 2 CK, taking USMLE can materially improve your chances. However, if your performance on COMLEX suggests that you would likely score poorly on USMLE as well, adding a low USMLE score can hurt. This decision is best made with guidance from a trusted advisor.

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3. Can strong research and letters truly compensate for a low Step 1 or Step 2 score?
They cannot erase your scores, but they can persuade programs to look beyond them, especially if your research is in vascular topics and your letters are exceptional and specific. For programs that perform strict score-based filtering, research won’t get you past the initial screen. But for mid-tier and DO-friendly programs with more holistic review, a robust research portfolio and glowing letters can be decisive, particularly if they attest to your clinical excellence and technical potential.

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4. How many programs should I apply to if I have below average board scores for vascular surgery?
With low scores, you should err on the side of applying broadly. For integrated vascular surgery, that may mean applying to nearly every program where you meet basic requirements. However, you should strongly consider applying to a large number of categorical general surgery programs as well—often 40–60+—with a clear plan to pursue vascular fellowship. Tailor your application and letters for both, emphasize your commitment to vascular surgery, and be open-minded about geographic location and program type.

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If your dream is vascular surgery, low scores do not automatically end that dream. They simply make the path more complex and require deliberate strategy. With careful planning, honest self-assessment, and a willingness to consider alternative routes (like general surgery first), you can still build a fulfilling career in this demanding and rewarding specialty.