Essential Strategies for DO Graduates with Low Step Scores in Residency

Understanding What a “Low Step Score” Really Means for a DO Graduate

For many DO graduates, seeing a lower-than-expected USMLE Step 1 or Step 2 CK score (or COMLEX Level 1/2-CE) can feel like the end of the world—especially in a competitive residency landscape. It isn’t. Matching with low scores is absolutely possible, particularly for osteopathic applicants who understand how to strategically leverage their strengths and target the right programs.

Before you can build a strong plan, you need clarity on what “low” actually means and where you stand:

• Context matters:

  • A “low Step 1 score” may be different for internal medicine vs. dermatology.
  • For some community programs, scores near the national mean may be fine; for highly academic programs, they may be considered low.

• USMLE vs. COMLEX (for DOs):

  • Many ACGME programs now accept COMLEX alone, but others still heavily favor or require USMLE.
  • If you took only COMLEX, your strategy differs from a DO who took both COMLEX and USMLE.
  • If you have below average board scores on both, you’ll need to rely more heavily on other parts of your application.

• Absolute vs. relative “low”:

  • Slightly below average: Often manageable with strong clinical grades and letters.
  • Significantly below average or failed attempt: Requires a more deliberate, targeted strategy and sometimes a longer timeline.

The goal is not to deny reality but to reframe it: your scores are one piece of your application, not your entire identity as a future physician. As a DO graduate, you already bring a holistic, patient-centered foundation. Now you’ll build a strategic application around that.

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Step 1: Honest Self-Assessment and Strategic Specialty Choice

The biggest mistake applicants with low scores make is ignoring their risk factors and applying as if they are average or above-average candidates. You need a brutally honest starting point.

1. Map Out Your Academic Profile

Write down:

• Board scores
  • USMLE: Step 1 (if numeric), Step 2 CK
  • COMLEX: Level 1, Level 2-CE
  • Any failed attempts or retakes
• Clinical metrics
  • Core clerkship grades (especially IM, Surgery, Pediatrics, OB/Gyn, Psych, Family Medicine)
  • Honors or internal ranking (if available)
• Other strengths
  • Research, quality improvement, conference presentations, leadership roles
  • Significant life experience or non-traditional background
  • Strong osteopathic identity (OMM involvement, leadership in SOMA/ACOI/ACGME interest groups)

This gives you a realistic “snapshot” beyond your scores.

2. Understand Specialty Competitiveness (and Where DOs Fit)

If you have markedly low board scores as a DO graduate, some specialties will be extremely difficult (e.g., dermatology, plastic surgery, neurosurgery, radiation oncology, competitive orthopedics). That doesn’t mean impossible for every individual, but the risk of going unmatched is very high.

Specialties that may be more forgiving of a low Step 1 score or below-average board scores, especially for DOs, include:

• Family Medicine
• Internal Medicine (particularly community-based)
• Pediatrics
• Psychiatry
• Physical Medicine & Rehabilitation (PM&R) – moderate, but DO-friendly
• Neurology (selected programs)
• Pathology (depending on region)
• Transitional Year (in combination with a less competitive advanced specialty)

More competitive (but still attainable for some DOs with a low Step 1 score and stronger Step 2, clinical record, and networking):

• Emergency Medicine (depending on region, SLOEs, and other factors)
• Anesthesiology
• General Surgery (especially community, DO-friendly programs)

3. Align Specialty Choice with Reality and Passion

Ask yourself:

• Am I genuinely interested in a less competitive specialty that’s more forgiving of low scores?
• If I’m set on a competitive field, am I willing to:
  • Take an extra year for research or a preliminary/transitional year?
  • Move anywhere in the country?
  • Accept a high risk of going unmatched?

Example
A DO graduate with a 195 Step 1, 225 Step 2 CK, and average clinical grades may have limited chances at EM in major academic centers but can be a strong candidate for community internal medicine or family medicine, especially with good letters and evidence of commitment to primary care.

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Step 2: Maximizing Every Other Part of Your Application

When your board scores are a relative weakness, everything else must become a strength. This is where DO graduates often shine—through clinical acumen, interpersonal skills, and holistic care.

1. Clinical Performance and Sub-Internships (Sub-Is)

Strong clinical performance can counterbalance low scores. Program directors repeatedly emphasize:

• Dependability
• Work ethic
• Being enjoyable to work with
• Strong patient care and communication skills

For DO graduates, targeted audition rotations and sub-internships are especially powerful.

Tactics:

• Prioritize rotations at DO-friendly programs you’d be happy to attend.
• Ask early about doing away rotations/sub-Is in your preferred region and specialty.
• Treat every day like a one-month interview:
  • Be early and prepared.
  • Volunteer for tasks.
  • Take ownership of patient follow-up and documentation.
  • Ask for mid-rotation feedback and adjust quickly.

2. Letters of Recommendation: Your Most Powerful Weapon

For applicants with low scores, letters of recommendation (LORs) can significantly shift program perceptions.

Aim for:

• 3–4 strong, specialty-specific letters (depending on ERAS requirements).
• At least one letter from:
  • A program director or clerkship director in your chosen specialty.
  • A physician who directly worked with you on an inpatient service or sub-I.

Tell potential letter writers:

• “My board scores are not where I hoped; a strong letter from someone who has seen me clinically would really help demonstrate my capabilities.”
• Provide them with your CV, personal statement draft, and your strengths you hope they’ll highlight (clinical judgment, work ethic, teachability).

Red flag to avoid: Generic letters (“hard-working, pleasant”) that don’t differentiate you. Better to have 3 outstanding letters than 4-5 average ones.

3. Personal Statement: Addressing Low Scores Strategically (or Not)

You don’t always have to explicitly mention a low Step 1 score in your personal statement, but there are times when it can be helpful:

• When to address it:

  • You had a concrete, time-limited issue (illness, major life event).
  • You rebounded with a significantly stronger Step 2 CK/COMLEX Level 2.
  • You can clearly articulate what changed in your study strategies and habits.

• How to address it:

  • Be brief, factual, and accountable.
  • Focus on what you learned and how you improved.

Example language
“During preparation for Step 1, I struggled to balance personal circumstances and effective study strategies, resulting in a score below my potential. I took this as a catalyst to re-evaluate my approach, seek mentorship, and develop a structured, data-driven study plan. These changes are reflected in my stronger performance on Step 2 and in my clinical rotations.”

Avoid lengthy justifications or blaming. The point is to show growth and resilience, not excuses.

4. CV and “Differentiators” for DO Graduates

Capitalize on your unique background:

• Osteopathic identity:
  • Involvement in OMM clinic, osteopathic-focused community projects, or leadership in osteopathic organizations.
• Service and leadership:
  • Free clinics, health fairs, patient education projects, advocacy work.
• Research or scholarly activity:
  • Any poster, QI project, case report, or academic presentation.

For someone with low scores, even smaller scholarly projects can help show engagement and intellectual curiosity.

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Step 3: Building a DO-Friendly, Score-Savvy Application Strategy

Low Step score strategies for DO graduates must be data-driven, not wishful. You need to build a list focusing on realistic outcomes and DO-friendly programs.

1. Identify DO-Friendly and Score-Flexible Programs

Use:

• FREIDA (AMA): Filter by specialty, state, and check past resident profiles.
• Program websites: Many now explicitly state they accept COMLEX, and some post average resident scores.
• Osteopathic networks:
  • Alumni from your DO school.
  • Residents or faculty you met on rotations.
  • DO-focused forums or national specialty organizations.

Look for:

• Programs historically matching DO students.
• Community-based rather than big-name, high-research academic centers.
• Programs not explicitly listing high score cutoffs on their websites or in ERAS.

2. Right-Sizing Your Application Numbers

Applicants with weak scores often underestimate how many programs they need to apply to, especially in moderately competitive specialties.

Rough guidance (varies by specialty and year):

• For highly DO-friendly fields (FM, many community IM, Psych):
  • Low scores may warrant applying to 30–60+ programs.
• For moderately competitive fields (EM, Anesthesia, Surgery, PM&R):
  • Consider 60–100+ programs if possible, and be geographically flexible.
• If applying in a competitive specialty with low scores:
  • Strongly consider dual applying (e.g., EM + IM, Anesthesia + IM, Surgery prelim + categorical backup).

3. Geographic Flexibility and “Hidden Gem” Programs

Your willingness to relocate can dramatically improve your chances:

• Be open to:
  • Midwest, South, and less densely populated regions.
  • Newer programs or those in smaller cities.
• Research “hidden gem” programs through:
  • Alumni networks
  • Conference networking
  • Cold emailing residents or program coordinators to ask if DOs are welcomed and what they value.

Example
A DO graduate with a 205 Step 1 and 220 Step 2 CK limited to California and New York may struggle to match IM. The same applicant willing to apply widely in the Midwest and South, focusing on DO-friendly community IM programs, often ends up with multiple interviews.

4. The Role of USMLE for DOs with Low COMLEX Scores

If you are a DO graduate with:

• Only COMLEX scores that are below average or near pass level, and:
• You are targeting specialties or programs that still prefer USMLE…

You face a tough decision:

• Already graduated:
  • Adding USMLE now (especially Step 2 CK) might help if you can perform significantly better than your COMLEX scores.
  • If your test performance pattern is consistently low, the risk of another marginal score—or a fail—may outweigh the benefit.
• If you already took USMLE and they’re low:
  • You can’t undo them; focus instead on programs that accept COMLEX and emphasize holistic review.

This decision is high-stakes; consult:

• Your school’s dean’s office or career advising
• Trusted faculty mentors
• Recent grads from your school who matched with similar profiles

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Step 4: Interview Season and Post-Interview Strategy with Low Scores

Getting interviews with low scores is only half the battle. Your performance during and after interviews can significantly influence your rank position.

1. Pre-Interview Preparation

Go in assuming every interview is precious:

• Know your application thoroughly:
  • Be ready to discuss any low Step 1 or COMLEX Level 1 score, if asked.
  • Have a short, composed explanation and pivot to your growth.
• Research each program:
  • Understand their mission, patient population, and any DO presence.
  • Prepare program-specific questions to demonstrate genuine interest.
• Practice:
  • Mock interviews with advisors, residents, or friends.
  • Focus on behavioral questions: teamwork, conflict, resilience, and mistakes you’ve learned from.

When asked about scores, a good approach is:

1. Own it briefly: “My Step 1 score is lower than I had hoped.”
2. Explain context without dwelling: One or two sentences on why.
3. Highlight growth: Focus on improved strategies, Step 2 performance, and clinical evaluations.
4. Connect to residency readiness: Emphasize that the habits you built will carry into your training.

2. Showcasing DO Strengths During Interviews

As a DO graduate, lean into your strengths:

• Emphasize patient-centered care, communication skills, and team-based practice.
• If your specialty values procedural or hands-on skills, mention your experience with OMM and manual techniques (even if you won’t use OMM daily).
• Share meaningful patient stories that reflect empathy, cultural humility, and persistence.

Programs often value “good people” who will work hard and fit their team culture more than a marginal difference in scores.

3. Communicating Interest Ethically and Effectively

Programs know that applicants with low scores sometimes “oversell” their interest. Be strategic and honest.

• Signal genuine interest by:
  • Thank-you emails that reference specific program features.
  • Occasional, brief update emails if something new appears on your CV (publication, award, new responsibility).
• Avoid:
  • Over-emailing or sounding desperate.
  • Making promises to multiple programs that you intend to rank them #1.

If there is a program where you would truly be happy, especially if they are DO-friendly and within your realistic range, it is fine to send a single, honest “top choice” note late in the season—if that aligns with your true rank intentions.

4. Ranking Strategy When You Have Low Scores

When you reach the rank list stage, be both optimistic and realistic:

• Rank all programs where you would be willing to train, regardless of perceived competitiveness.
• Don’t play “games” by ranking only a few “dream” programs; that is one of the fastest paths to going unmatched with low scores.
• Balance:
  • Reach programs you interviewed at but feel are less likely.
  • Realistic community or DO-friendly programs where you felt comfortable and connected.

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Step 5: If You Don’t Match: Strategic Next Steps for DO Graduates

Even the best low Step score strategies sometimes end in an unmatched outcome. This is not the end of your career; it is a painful detour that requires rapid re-planning.

1. SOAP (Supplemental Offer and Acceptance Program)

If you go unmatched:

• Prepare ahead of time:
  • Have updated documents ready.
  • Review how SOAP works before Match Week.
• During SOAP:
  • Be broad and flexible: consider preliminary, transitional, or less competitive specialties.
  • Lean heavily on advisors to help prioritize programs that are likely to consider a DO with your scores.

2. Post-SOAP: Intentional Gap Year

If you remain unmatched after SOAP, you have options:

• Research or academic year:
  • Particularly valuable if you want a more competitive specialty.
  • Try to embed yourself in a department that has a residency program.
• Clinical experience:
  • Hospitalist scribe, research coordinator, clinical assistant in underserved clinics, or non-resident physician roles (varies by state and institution).
• Focused board improvement:
  • If you failed an exam or barely passed, a dedicated year for:
    • Test-taking coaching
    • Structured remediation
    • Retaking exams where appropriate (if allowed and advised)

Use this time to build a clear narrative of growth and perseverance.

3. Re-Application Strategy

On your second cycle:

• Meet with advisors and ask for brutally honest feedback.
• Adjust:
  • Specialty choice (if needed)
  • Geography
  • Number and types of programs
• Strengthen:
  • New letters from your gap-year mentors or researchers.
  • Evidence of sustained engagement in medicine.

Many DO graduates have successfully matched on their second attempt, even with low initial scores, after a focused and strategic gap year.

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Frequently Asked Questions (FAQ)

1. Can I still match into residency as a DO graduate with a low Step 1 score or low COMLEX Level 1?

Yes. Many DO graduates with low or below-average board scores successfully match every year, especially into DO-friendly, less competitive specialties and community-based programs. Your odds improve significantly if you:

• Choose a realistic specialty and geography
• Apply broadly
• Excel clinically and obtain strong letters of recommendation
• Demonstrate growth through a stronger Step 2/Level 2 and solid rotations

2. Should I address my low Step 1 score in my personal statement?

It depends. You should consider addressing it briefly if:

• There was a time-limited, significant issue (illness, family crisis) that affected your exam.
• You can show clear improvement on Step 2/Level 2 and in clinical rotations.
• You can frame it as a story of resilience, growth, and better habits.

If your score is modestly low and not out of proportion to the rest of your application, it may be better to focus your personal statement on your motivations, experiences, and strengths rather than on remediation.

3. How many programs should I apply to if I have below average board scores?

The exact number depends on your specialty, geography, and other strengths, but in general:

• For DO-friendly, less competitive fields (FM, many IM, Psych), low-score applicants might target 30–60+ programs.
• For moderately competitive fields (EM, Anesthesia, Surgery, PM&R), low-score DO applicants often need 60–100+ programs and wide geographic flexibility.
• For very competitive fields, you should strongly consider dual applying (e.g., your dream field plus IM or FM) to reduce the risk of going unmatched.

4. As a DO, do I really need USMLE if my COMLEX scores are low?

Not always, but it’s complicated:

• If you have already graduated and have only COMLEX with low scores:
  • Adding USMLE Step 2 CK may help if you’re confident you can score significantly higher and you’re targeting programs that strongly favor USMLE.
  • If your test-taking history suggests you may again underperform, taking USMLE might not help and could hurt.
• If you already took USMLE and scores are also low:
  • Focus on programs that explicitly accept and understand COMLEX and emphasize holistic review.
  • Strengthen every non-test part of your application.

This decision is best made with personalized guidance from your school’s advising office and mentors familiar with your full situation.

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Low Step score strategies for a DO graduate are not about hiding weaknesses—they’re about owning your story, amplifying your strengths, and executing a disciplined plan. With realistic specialty choices, strong clinical performance, DO-friendly program targeting, and a resilient mindset, matching with low scores is not only possible—it happens every year.