Strategies for DO Graduates: Navigating Low Step Scores in Surgery Residency

Understanding the Challenge: Low Scores in a Competitive Surgical World

General surgery is one of the most competitive specialties in the residency match. For a DO graduate with a low Step 1 score, below average board scores, or mixed USMLE/COMLEX performance, the pressure can feel overwhelming. Many applicants assume that a weak test score automatically closes doors to a surgery career.

That’s not accurate.

Low scores absolutely make the surgery residency match harder—but not impossible. Program directors are open about what scores mean: they are one data point among many, and they care deeply about how you perform in clinical settings, your letters, your grit, and your commitment to surgery.

In this article, we’ll focus specifically on low Step score strategies for a DO graduate targeting general surgery, including:

• How to realistically assess your competitiveness
• What matters more than your test scores—especially for DOs
• Targeted tactics to offset low scores in the osteopathic residency match and ACGME programs
• Application and interview strategies tailored for matching with low scores
• When to consider backup plans without giving up your surgical ambitions

Throughout, we’ll integrate the keywords and scenarios most relevant to you: DO graduate residency, general surgery residency, surgery residency match, and the realities of applying with below average board scores.

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Step 1: Honest Self-Assessment and Strategic Targeting

Before you can build a strategy, you need a clear-eyed assessment of where you stand.

Define “Low” in Context

“Low Step 1 score” is relative and has evolved since Step 1 became Pass/Fail. Program directors now lean more heavily on:

• USMLE Step 2 CK (or COMLEX Level 2-CE)
• Clinical performance and letters
• School reputation and known performance standards

For the purpose of strategy, “low” typically means:

• USMLE Step 2 CK:

  • Competitive general surgery programs: often looking for ~245+
  • Mid-range: ~235–245
  • “Low” in this context: <230, particularly <225

• COMLEX Level 2-CE:

  • Highly competitive: ~650+
  • Mid-range: ~600–650
  • “Low”: <550, particularly <520

Your exact numbers are less important than how you frame and mitigate them.

Combine Scores with the Rest of Your Profile

You’re not just a test score. Assess yourself across five domains:

1. Board Scores

   • Step 1: Pass vs multiple attempts
   • Step 2 CK / Level 2-CE: exact score, attempts, trajectory

2. Clinical Performance

   • Surgery clerkship grade (Honors/High Pass/Pass)
   • Other core clerkship performance
   • Sub-I / acting internship in surgery

3. Surgical Exposure & Commitment

   • Number and quality of general surgery rotations
   • Away rotations / audition rotations in surgery
   • Surgical research, QI projects, case reports
   • Membership in surgical interest groups, ACS, etc.

4. Letters of Recommendation

   • At least 2–3 strong letters from general surgeons
   • Ideally, one from a program director or department chair
   • Any letters commenting on your technical skill, work ethic, and “fit” for surgery

5. Personal / Professional Factors

   • DO graduate status (perceived bias varies by region and program)
   • Geographic ties (home state/region)
   • Red flags: professionalism, failed rotation, disciplinary issues

Tier Your Target Programs

Instead of applying blindly, create three tiers:

• Tier 1 (Reach Programs)
  University-based or high-reputation academic programs, often with many research fellows and strong Step statistics. You can apply, but don’t rely on them.

• Tier 2 (Realistic Programs)

  • Community-based ACGME general surgery residencies
  • Some university-affiliated community programs
  • Programs with a history of taking DOs and applicants with a broader score range

• Tier 3 (Safety / Backup within Surgery)

  • Smaller community programs, including those in less desirable locations
  • Programs with a significant proportion of DO graduates
  • Preliminary general surgery positions (we’ll discuss pros/cons later)

Your goal with below average board scores is to heavily weight applications toward realistic and safety programs while still including some reach programs.

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Step 2: Maximizing Non-Score Factors as a DO Applicant

For a DO graduate residency applicant in general surgery, non-score components often become your biggest advantage. DO training emphasizes hands-on clinical care, patient communication, and osteopathic principles—traits that align very well with surgical culture when clearly demonstrated.

Build a Surgical Identity

Program directors want to see that you’re a future surgeon, not just someone who picked surgery last minute.

Key ways to signal this:

1. Surgery-Focused Rotations

   • Aim for at least one sub-internship (Sub-I) in general surgery at your home institution (if available).
   • Add 1–2 away rotations at realistic target programs. These function as “month-long interviews” and are essential in the surgery residency match if your scores are weaker.

2. Consistent Surgical Activities

   • Active leadership in a surgery interest group
   • Shadowing and longitudinal mentorship with general surgeons
   • Attendance at morbidity & mortality (M&M) conferences, tumor boards, journal clubs

3. Research and Quality Improvement

   • You don’t need a first-author paper in a high-impact journal to match, especially as a DO. Instead:
     • Case reports or clinical vignettes
     • QI projects (e.g., reducing post-op infection rates)
     • Retrospective chart reviews supervised by a surgeon
   • Aim for 1–3 tangible products (poster, abstract, or publication) to demonstrate academic engagement.

Craft Outstanding Letters of Recommendation

Strong letters can directly counteract concerns about matching with low scores.

Target:

• 2–3 letters from general surgeons who have supervised you closely
• Ideally:
  • 1 from your Sub-I at a target program
  • 1 from a home institution surgeon who knows you well
  • 1 from a department chair or program director if possible

Ask letter writers explicitly to:

• Comment on your work ethic and reliability
• Describe your technical skills and progression (e.g., suturing, assisting in the OR)
• Compare you to other students they’ve worked with (“top 10% of students I’ve supervised”)

If you’re a DO graduate who has done an audition rotation at an ACGME program, a strong letter from that program can significantly boost your credibility in the osteopathic residency match and beyond.

Emphasize Clinical Performance and Professionalism

Low board scores raise two questions in a PD’s mind:

1. Are you able to handle the cognitive load of surgery training?
2. Are there broader professionalism or work ethic concerns?

Your clinical evaluations and narrative comments can reassure them:

• Highlight Honors/High Pass in surgery and other core rotations
• Pull key phrases from narratives into your CV or personal statement (e.g., “Residents consistently praised my intern-level work ethic and reliability”)
• Show a pattern of strong end-of-rotation comments that emphasize:
  • Initiative
  • Teamwork
  • Ability to take feedback
  • Calmness under pressure

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Step 3: Strategic Use of Step 2 CK / Level 2-CE and Retesting Decisions

With Step 1 now Pass/Fail, Step 2 CK and Level 2-CE often carry additional weight, especially if you’ve already signaled some academic vulnerability.

Aim for a Strong Upward Trajectory

If you had:

• A marginal Step 1 pass
• Below average COMLEX Level 1
• Or a failed attempt (that you eventually passed)

Then Step 2 CK / Level 2-CE is your chance to prove academic recovery.

Actions:

1. Delay Application if Necessary
   If you can delay taking Step 2 CK by a few months to prepare properly and significantly increase your score, this is usually worth it—especially in general surgery. A strong Step 2 CK/Level 2-CE is one of the most powerful tools for matching with low scores from earlier exams.

2. Structured Study Plan

   • Dedicated 6–8 weeks, more if your prior scores were low
   • Heavy focus on:
     • Surgery, internal medicine, and emergency medicine content
     • Practice questions (UWorld, COMBANK, etc.)
   • Weekly full-length practice tests to track improvement

3. Narrative of Improvement

   • In your personal statement and interviews, emphasize:
     • Lessons learned from earlier exams
     • Specific changes in study methods
     • How this reflects your ability to adapt and improve—critical traits for surgery

Handling Multiple Attempts or Very Low Scores

If you have multiple attempts on any exam, especially Step 2 CK/Level 2-CE:

• Do not hide it; PDs see all attempts.
• Prepare a 1–2 sentence, straightforward explanation:
  • “I struggled initially with standardized test anxiety and inefficient study strategies, which led to a failed attempt. I then sought faculty mentorship, restructured my study approach, and ultimately passed on the second attempt. My improved performance in clinical rotations reflects that growth.”

Avoid:

• Long, emotional explanations
• Blaming the test, school, or circumstances
• Over-sharing personal issues unless truly relevant and stabilized

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Step 4: Application Strategy for the Surgery Residency Match as a DO

When your scores are not your strength, your application strategy can make or break your chances.

Cast a Wide but Informed Net

General surgery is competitive even for applicants with strong scores. For a DO with a low Step 1 score or below average board scores, the number of applications should be higher than average.

Typical ranges:

• MD with solid scores: 30–50 general surgery programs
• DO with low scores: 60–100+ programs, depending on your risk tolerance and other strengths

But more important than the number is which programs you choose:

• Prioritize:
  • Programs that have historically matched DOs
  • Community and university-affiliated community programs
  • Geographic regions with less intense competition (certain Midwest, South, or rural areas)
• Use:
  • FREIDA, program websites, and match lists to confirm DO-friendliness
  • Current residents (especially DOs) for informal insight via email or networking

Optimize Your ERAS Application

Your ERAS application needs to tell a coherent story: you are a hard-working, surgically committed DO who has grown from academic challenges.

Key components:

1. Personal Statement

   • Address low scores briefly, if at all, unless there’s a major red flag.
   • Emphasize:
     • Your path to discovering general surgery
     • Specific clinical experiences that defined your interest
     • Traits essential to surgery: resilience, teamwork, attention to detail
   • If needed, include a concise explanation of score issues followed by a clear pivot to your growth and performance in the clinical environment.

2. Experiences Section

   • Elevate surgery-relevant clinical and leadership experiences:
     • Sub-Is / acting internships
     • Surgical research
     • Leading an interest group, QI projects, or teaching juniors
   • Use action verbs and outcome-focused descriptions:
     • “Collected and analyzed data on 120 postoperative patients, contributing to a QI initiative that reduced surgical site infections by 10%.”

3. Program Signaling / Geographic Ties (If Applicable)

   • Some cycles include preference signaling. If so, use all signals on realistic programs that:
     • Take DOs
     • Have your geographic ties or where you did away rotations
   • Explicitly mention ties to a region (family, prior training, long-term plans) in your application or supplemental essays.

Consider Preliminary Surgery Spots Carefully

Preliminary (prelim) general surgery positions are one-year contracts without a guaranteed categorical (full-length) spot. For an applicant matching with low scores, prelim positions can:

Pros:

• Get you into surgery, prove yourself in a residency setting
• Offer opportunities to transition to categorical if spots open (via attrition or expansion)
• Strengthen your CV if you plan to reapply to surgery or switch to another specialty

Cons:

• No guarantee of a categorical spot
• Highly demanding with uncertain future
• Some programs offer minimal support for prelims

You should:

• Apply to some prelim programs as insurance, not your primary plan
• Ask very directly (in interviews) about:
  • Historical transition rates from prelim to categorical
  • Support for prelim residents (case volume, mentorship, career guidance)

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Step 5: Interview and Post-Interview Tactics to Overcome Low Scores

Once you get interviews, you’ve already passed the biggest screen. Many programs won’t invite applicants they’re unwilling to rank. Now your job is to reassure, connect, and stand out.

How to Talk About Low Scores Confidently

Program directors may ask directly:
“Can you tell me about your USMLE/COMLEX performance?”

Respond with:

1. Ownership

   • “My early exam performance did not reflect my potential or work ethic.”

2. Specific Lessons

   • “I learned that I was relying too heavily on passive review instead of active problem-solving.”

3. Demonstrated Change

   • “I worked with faculty to create a structured study plan and used question-based learning, which improved my clinical performance and Step 2 CK results.”

4. Link to Residency Readiness

   • “The same disciplined, adaptive approach I used to improve academically is how I now approach challenging clinical situations and feedback.”

Avoid:

• Overly long explanations
• Implying the score doesn’t matter at all
• Emotional blame or excuses

Showcase Strengths Typical of DO Graduates

As a DO, you often bring experiences that resonate with surgical training:

• Strong bedside manner and team collaboration
• Early clinical exposure and hands-on skills
• Comfort with holistic and longitudinal care

In interviews:

• Give examples of hard cases where you stayed late, followed up, or took extra responsibility
• Describe situations where you:
  • Helped calm an anxious OR patient
  • Identified a subtle clinical sign that changed management
  • Took initiative in a QI or research project

Rank List Strategy and Communication

After interviews:

1. Rank programs in your true preference order
   The algorithm favors applicant preference—not game theory based on perceived competitiveness.

2. Consider Sending Thoughtful (Not Excessive) Communication

   • A sincere thank-you email to programs you’re truly interested in
   • A single “#1 letter of intent” to your top choice (if acceptable per program policies and match rules)
   • Focus on fit: surgical volume, resident culture, alignment with your goals, and geographic ties.

3. Avoid Over-Interpreting Silence

   • Many programs do not send post-interview signals.
   • Ranking is often based on faculty consensus and holistic review.

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When and How to Consider Backup Paths Without Abandoning Surgery

Not everyone will match general surgery on the first try, especially with low Step 1 scores or multiple exam attempts. This doesn’t mean you must give up your goal.

Reasonable Backup Specialties

For some DO graduates, it may be wise to dual-apply to:

• Categorical Preliminary-Adjacent Fields
  • Transitional year programs
  • Preliminary internal medicine
• Surgical-Adjacent Specialties
  • Anesthesiology
  • Interventional radiology (highly competitive, but sometimes more holistic)
  • PM&R with procedural focus

Or to consider:

• Less competitive, procedurally rich fields
  • Family medicine with strong outpatient procedures
  • Internal medicine with endoscopy/point-of-care ultrasound / ICU pathways
  • Emergency medicine (though this has its own competitiveness cycles)

Taking a Gap Year

A deliberate gap year can be valuable if used well:

• Join a surgical research fellowship (ideally at an institution with a general surgery residency)
• Work as a surgical assistant or research coordinator
• Gain more publications, mentorship, and letters

For a DO applicant, especially one facing the osteopathic residency match and ACGME match realities, a gap year focused on surgery can:

• Deeply strengthen your CV
• Provide insider pathways into programs
• Show long-term commitment that overrides early exam performance

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

1. As a DO graduate with a low Step 1 score, do I still have a realistic chance to match into general surgery?
Yes, but your path will be more challenging and require a strategic, comprehensive approach. DOs successfully match surgery every year with below-average scores, particularly when they:

• Excel on Step 2 CK / Level 2-CE or show clear improvement
• Perform strongly on surgery rotations and sub-Is
• Obtain excellent letters from general surgeons
• Apply broadly to DO-friendly and community-based programs
• Are open to prelim spots or backup specialties if needed

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2. How many general surgery programs should I apply to if my scores are below average?
For a DO applicant with low or borderline exam scores, consider:

• 60–100+ general surgery applications, weighted toward:
  • Community and university-affiliated community programs
  • Programs with a track record of accepting DOs
  • Regions where competition is somewhat less intense

You can also add some preliminary general surgery programs and possibly dual-apply to a backup specialty if advised by your mentors.

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3. Should I address my low scores in my personal statement?
Only if there is a clear reason to, such as a failed attempt or a dramatic improvement story. When you do:

• Keep it to 1–3 concise sentences
• Take responsibility without excessive detail
• Emphasize what you learned and how you improved
• Immediately pivot to your strengths—clinical performance, surgical commitment, and readiness for residency

If your scores are just slightly below average but not catastrophic, it’s often better to focus the personal statement on your journey toward surgery and strengths rather than on exam explanations.

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4. Is a preliminary general surgery spot a good idea for a DO with low scores?
It can be, but it depends on the program and your risk tolerance.

A prelim year may be a good option if:

• The program has a documented record of prelims moving into categorical spots (locally or elsewhere)
• You’re prepared for a demanding year with uncertain outcome
• You were unable to secure a categorical position but remain firmly committed to surgery

It may not be ideal if:

• You have significant debt and cannot afford a year without a clear long-term plan
• The prelim program offers little mentorship or support

If considering prelim positions, ask very specific questions about outcomes, support, and expectations before ranking.

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A low Step score or below average board scores do not define you or your career. As a DO graduate aiming for general surgery residency, you can still be a compelling candidate by building a strong surgical identity, maximizing clinical performance and letters, demonstrating academic growth, and approaching the surgery residency match with a thoughtful, data-driven strategy.