Essential Strategies for DO Graduates with Low Step Scores in the Midwest

Understanding the Challenge: Low Scores as a DO in the Great Lakes Region

For a DO graduate in the Great Lakes Region, a low Step 1, Step 2, or COMLEX score can feel like a permanent barrier to residency. It isn’t. It does mean your path will be more strategic and deliberate—but many applicants with below average board scores successfully match into solid programs every year, including in competitive metro areas like Chicago, Detroit, Cleveland, and Minneapolis.

This article is tailored to you as a DO graduate aiming for Midwest residency programs, especially Great Lakes residency sites, and worried about:

• A low Step 1 score (or COMLEX Level 1)
• Step 2/COMLEX Level 2 not as high as you hoped
• Failed attempts or score gaps
• Concerns about the osteopathic residency match in the current ACGME single accreditation system

We’ll focus on realistic, evidence-informed strategies that can improve your odds of matching with low scores, especially in programs and specialties that remain DO-friendly.

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Reframing “Low Scores”: Where You Actually Stand

Before planning a strategy, you need to define what “low” means in your context.

What Counts as a “Low Step 1 Score” or “Below Average Board Scores”?

(For those who took Step 1 before pass/fail; for recent graduates, substitute COMLEX Level scores or Step 2 CK.)

• Below average: Roughly < 220 on Step 1 or < 230 on Step 2 CK; COMLEX Level ~ < 500
• Significantly low: Step scores in the 205–215 range; COMLEX < 475
• Red-flag territory: Failure on Step/COMLEX, multiple attempts, or score well below national mean

For DO graduates, program directors often view COMLEX and USMLE together, if you took both. If you didn’t take USMLE, many Great Lakes programs (especially community-based and historically osteopathic sites) are comfortable with COMLEX-only applicants.

How Program Directors Think About Low Scores

Program directors rarely reject or accept an applicant due to scores alone. They look at:

• Risk vs. benefit: Will this resident pass boards and complete training?
• Evidence of upward trend: Improved performance over time (e.g., higher Step 2/Level 2, strong clerkship grades)
• Fit for their setting: Community vs. academic, service needs, night coverage, underserved populations
• Professionalism and work ethic: Reflected in letters, rotation performance, and interview behaviors

A low score raises concern, but a clear, data-backed recovery story plus strong clinical performance can offset it—especially in specialties and regions with historically more DO-friendly culture (like Family Medicine, Internal Medicine, Pediatrics, and PM&R in the Midwest and Great Lakes region).

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Targeting the Right Programs in the Great Lakes Region

The most powerful lever for matching with low scores is careful program selection. Where you apply often matters more than what you scored.

1. Focus on DO-Friendly and Holistically Reviewing Programs

In the Great Lakes Region (Illinois, Indiana, Michigan, Ohio, Wisconsin, Minnesota, New York and Pennsylvania parts near the lakes), many programs have strong osteopathic traditions or large numbers of current DO residents.

Look for programs that:

• Have multiple DO residents or faculty
• Historically participated in the former AOA-accredited system
• Explicitly list COMLEX scores in their requirements
• Emphasize holistic review and fit over numerical cutoffs on their websites

Examples of program characteristics (not specific endorsements, but patterns to seek):

• Community-based teaching hospitals in mid-sized Great Lakes cities (e.g., Toledo, Erie, Kalamazoo, Rockford, Green Bay)
• Health systems with osteopathic heritage (e.g., systems in Michigan and Ohio that previously hosted osteopathic residencies)
• Programs affiliated with DO schools in the Midwest (MSUCOM, OU-HCOM, CCOM, LECOM, etc.)

2. Expand Beyond the “Big Name” Urban Academic Centers

It’s reasonable to apply to a few large academic programs in Chicago, Cleveland, or Detroit, but they often receive thousands of applications and can be more score-sensitive.

With low scores, you dramatically improve your odds by heavily targeting:

• Community and community-academic hybrid programs
• Smaller cities and regional centers (e.g., Akron, Fort Wayne, Peoria, Dayton, Saginaw, Duluth)
• Programs that serve rural or underserved populations in the Great Lakes region
• Newer programs still building reputation and applicant pipelines

3. Choose Specialties Strategically

If your scores are significantly below average, your specialty choice may matter more than anything else.

Generally more forgiving for DO graduates with low scores (especially in Midwest residency programs):

• Family Medicine
• Internal Medicine (particularly community-based)
• Pediatrics
• Psychiatry
• Physical Medicine & Rehabilitation (PM&R) at historically DO-friendly programs
• Transitional Year and Preliminary Medicine (for future specialty shifts)

More challenging with low scores (not impossible, but highly competitive):

• Dermatology, Orthopedic Surgery, Neurosurgery, ENT
• Integrated Plastics, Radiation Oncology
• Highly competitive academic EM or IM programs in major cities

If you’re set on a competitive specialty, you’ll need an even more focused strategy (research year, strong mentorship, geographic flexibility, potentially a “stepping stone” year in a prelim program).

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Strengthening Your Application Around a Low Score

You cannot change a past exam, but you can aggressively optimize everything else. The goal is to build a coherent, reassuring narrative: your low scores are an outlier in an otherwise strong application.

1. Maximize Step 2 / COMLEX Level 2 (If Still Pending)

If you haven’t taken Step 2 CK or COMLEX Level 2 yet, a strong performance is your single greatest corrective measure.

• Aim to score at or above the national mean or at least clearly above your previous performance.
• Create a structured study schedule with question banks (UWorld, COMQUEST/COMBANK).
• Treat this as your chance to show growth and academic resilience; mention this in your personal statement if successful.

If you already took Step 2 but underperformed:

• Emphasize consistent or improved clinical performance and strong letters.
• If you failed and then passed, explicitly frame what you changed and how you improved.

2. Leverage COMLEX Strength (If Applicable)

As a DO graduate, your COMLEX scores matter, particularly for osteopathic-friendly programs:

• If your Step 1 is low but your COMLEX Level 1 or Level 2 is average or above, highlight your COMLEX scores in your ERAS application and personal statement.
• Some DO graduates with low Step scores but decent COMLEX match well into Great Lakes residency programs that are COMLEX-savvy.
• When emailing programs, you can politely note that your COMLEX scores more accurately reflect your capabilities.

3. Excel on Clinical Rotations—Especially in the Midwest

For applicants with below average board scores, audition rotations and core clerkships become critical:

• Prioritize away rotations or sub-internships at Great Lakes programs you’re realistically targeting.
• Treat every rotation as a month-long interview: show up early, know your patients in detail, be the resident’s right hand.
• Ask for specific, strong letters of recommendation from attendings who saw your work ethic and can explicitly counterbalance your scores:
  • “Despite being aware of his earlier test challenges, I have zero concerns about his ability to pass boards and practice independently.”

Strong clinical performance at a program—especially if they know your low scores upfront—can dramatically increase your chance of an interview and ranking.

4. Craft a Clear, Honest Personal Statement

Your personal statement can’t erase a low Step score, but it can frame it in context and show maturity.

Guidelines for addressing low scores:

• Acknowledge briefly and factually (1–2 sentences).
  • Example: “During my pre-clinical years, I struggled with standardized test strategies and time management, which contributed to my lower Step 1 score.”
• Emphasize what changed: study strategies, resource use, support systems, time management, wellness practices.
• Connect to improved performance: better clinical grades, better Level 2/Step 2 score, or observed growth.
• Avoid long excuses or emotional narratives; keep it professional and solution-focused.

Make sure the rest of the statement emphasizes:

• Your connection to the Great Lakes Region (family, training, desire to stay and serve the local communities).
• Why you are drawn to that specialty.
• Concrete examples of resilience, teamwork, and patient-centered care.

5. Get Surgical With Your Letters of Recommendation

For DO graduates in the Great Lakes area, letters from regional faculty can carry weight.

Aim for:

• 3–4 strong letters, ideally including:
  • One from your specialty of interest (e.g., IM, FM, Psych) who strongly endorses you.
  • One from someone who can address your clinical reasoning and reliability.
  • If appropriate, a mentor who can indirectly contextualize your test performance by emphasizing your success in complex real-world situations.
• Prefer letters from ACGME faculty in the Midwest (or from known regional systems) when possible.

Ask letter writers directly if they can “write a strong, supportive letter for residency applications”—this opens the door for them to decline if they cannot.

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Managing the Application Process: Volume, Signaling, and Communication

For applicants with below average board scores, the way you apply can be almost as important as what you submit.

1. Apply Broadly—but Intelligently

In most cases, applicants with low scores should:

• Apply to more programs than average in your specialty.
  • Example: For Internal Medicine, 60–100+ programs may be appropriate; for Family Medicine, 40–80.
• Use filters to find:
  • Programs that accept COMLEX-only (if you didn’t take USMLE).
  • Programs not listing strict minimum score cutoffs.
  • Community-based and DO-friendly programs in Great Lakes and broader Midwest.

Be realistic but not defeatist. Include:

• A core list of “high probability” community programs where your profile matches current residents.
• A secondary list of regional academic or mid-tier university-affiliated programs where you have some connection or strong interest.
• A few reach programs if you have unique strengths (strong research, prestigious letters, or compelling story).

2. Use Program Signals and Preference Signals (If Available)

Some specialties have implemented signal tokens or preference signaling in ERAS:

• Use your highest-priority signals on programs where you are truly willing to train and that are moderately attainable—not only on ultra-competitive places.
• Reserve signals for:
  • DO-friendly programs in the Great Lakes region.
  • Places you have rotated, have connections, or where your geographic ties are strong.

In a competitive landscape, a signal from a DO graduate with low scores can still raise your application in a mid-tier program’s stack.

3. Consider a Focused Geographical Strategy

Programs often favor applicants who are more likely to stay in the region. Emphasize:

• Being from the Great Lakes or Midwest originally.
• Family ties in the area.
• Prior training at a DO school in the Midwest.
• Interest in practicing in underserved communities in the region.

If you’re open to multiple states, note that your overall chance is higher if you consider the full Midwest (e.g., Iowa, Missouri, Kansas) in addition to core Great Lakes states.

4. Polite, Professional Communication With Programs

Programs differ in how they view emails, but used carefully, communication can help:

• Send brief, specific interest emails to programs where:

  • You have a genuine reason for liking the program (rotations, mentor recommendations, geographic ties).
  • Your score may be borderline but not disqualifying.

• Template framework:

  Dear Dr. [Program Director Name],

  My name is [Name], a DO graduate from [School] with strong ties to the Great Lakes region. I recently applied to your [Specialty] residency program and wanted to express my sincere interest, particularly in your [unique feature—clinic site, patient population, osteopathic recognition, etc.].

  While my [Step/COMLEX] scores are below the typical average, my clinical evaluations, letters of recommendation, and experiences at [clinical sites, including any in the region] more accurately reflect my capabilities. I would be grateful for consideration for an interview.

  Thank you for your time and for training physicians who serve our region.

  Sincerely,
  [Name], DO

Keep it concise, respectful, and avoid repeated follow-ups unless the program indicates they welcome updates.

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Interviewing and Ranking: Turning Your Story Into Strength

Once you get interviews, your scores become less central. Now your ability to connect, communicate, and reassure program directors becomes critical.

1. Preparing for Questions About Low Scores

You will likely be asked directly about your low Step 1 score or below average board scores. Prepare a polished 60–90 second answer:

Key components:

1. Acknowledgement: Admit the reality without defensiveness.
2. Insight: Show you understand why it happened (e.g., poor test strategy, life stressors, misaligned study habits).
3. Action: Explain concretely what you changed (tutoring, new resources, practice questions, time management, mental health support).
4. Evidence of improvement: Point to improved clinical grades, successful Step 2/Level 2, or sustained performance.
5. Reassurance: Emphasize that your current habits are stable and reliable.

Example answer:

During my pre-clinical years, I underestimated how different high-stakes board exams are from school tests. I relied too heavily on passive review and didn’t start question-based learning early enough, which contributed to my low Step 1 and Level 1 scores.

After that experience, I completely changed my approach. I joined a structured study group, focused on daily practice questions with active review, and met with a learning specialist to refine my test-taking strategies. Those changes helped me perform significantly better on my clinical rotations and Level 2, and I’ve maintained those habits throughout my sub-internships.

I’m confident that the systems I have in place now will support me in successfully passing my boards on the first attempt moving forward.

2. Highlighting Strengths That Matter More Than Scores

During interviews, lean into qualities that many Great Lakes residency programs particularly value:

• Work ethic and reliability in team-based care
• Experience with or commitment to underserved and rural communities
• Interest in continuity of care and long-term patient relationships
• Respect for interprofessional teamwork (nurses, social work, PT/OT, pharmacy)
• Osteopathic principles applied to patient-centered care (even if no OMM is used)

Share specific clinical stories that show you:

• Went the extra mile for patients
• Took responsibility after making a small mistake
• Stepped up during a busy call night
• Helped teammates succeed

3. Ranking Programs Strategically

When creating your rank list:

• Rank ALL programs where you’d be willing to train, in genuine order of preference—even if you think some are “safeties.”
• Don’t self-eliminate based on perceived competitiveness; the algorithm favors the applicant’s preferences.
• That said, with low scores, avoid ranking only a small cluster of competitive academic programs; include a substantial number of community and DO-friendly programs.

Consider:

• Geographic preferences (but maintain flexibility)
• Presence of DO faculty and alumni
• Board pass rates and support systems for residents
• Program culture (ask current residents during pre-interview socials or second looks)

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Contingency Planning: If You Don’t Match on the First Try

Even with an optimized strategy, some applicants with low scores will not match in their first cycle. This is not the end of your career, but it does require an organized Plan B.

1. SOAP (Supplemental Offer and Acceptance Program)

If you don’t match:

• Be immediately available during SOAP week.
• Work closely with your school’s advisors to:
  • Identify available preliminary, transitional, or categorical positions in the Midwest and beyond.
  • Apply widely to programs where your application could be competitive.
• Be open to:
  • Different specialties than your original plan.
  • Geographic flexibility beyond the Great Lakes region.

A solid preliminary year or categorical spot in a less competitive specialty can still lead to a fulfilling career—and sometimes even lateral moves down the road.

2. Gap Year Strategy

If you don’t secure a spot through SOAP, a structured gap year can improve your future prospects:

Options:

• Research year (especially at a Great Lakes academic center): Focus on clinical research, QI projects, and network building.
• Clinical experience: Working as a research assistant, clinical instructor, or in allied health roles that keep you close to patient care.
• Additional coursework or a master’s degree (less important than real clinical or research experience, but sometimes relevant).

During this time, shore up weaknesses:

• Consider re-taking an exam (if allowed and strategically sensible).
• Secure new, strong letters of recommendation.
• Publish or present posters or abstracts if aiming for academic programs.

The key is to show clear upward trajectory and persistence, not stagnation.

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FAQs: Low Step Score Strategies for DO Graduates in the Great Lakes Region

1. I’m a DO graduate with only COMLEX scores and a low Level 1. Can I still match into a Great Lakes residency without USMLE?
Yes, many Midwest residency programs—especially community-based and historically osteopathic—are comfortable with COMLEX-only applicants. Your focus should be on programs that explicitly accept COMLEX, have DO residents, and practice holistic review. A stronger Level 2, excellent clinical evaluations, and strong letters will matter more than the absence of USMLE.

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2. My Step 1 score is significantly below average, but Step 2 is closer to the mean. How should I present this?
Frame Step 2 as evidence of growth and adaptation. In your personal statement and interviews, briefly acknowledge the Step 1 difficulty, then emphasize what you changed (study methods, resources, time management) and how this led to a better Step 2/Level 2 performance and stronger clinical results. Many program directors value upward trends over a single early low score.

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3. How many programs should I apply to as a DO with below average board scores?
The exact number depends on your specialty, but in general, you should apply more broadly than the average applicant:

• Internal Medicine: often 60–100+ programs
• Family Medicine: 40–80
• Psychiatry / Pediatrics / PM&R: variable, but usually above specialty average
  Focus heavily on community and DO-friendly Great Lakes residency programs, with some extensions across the broader Midwest and beyond. Always balance breadth with realistic program choices.

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4. Which specialties are most feasible for matching with low scores as a DO in the Midwest?
You’ll have the best odds in specialties that traditionally place stronger emphasis on holistic review and workforce needs, such as:

• Family Medicine
• Internal Medicine (especially community-based)
• Pediatrics
• Psychiatry
• PM&R at DO-friendly sites

Surgical and highly competitive subspecialties are not impossible, but they typically require additional strengths (research, strong specialty mentors, excellent Step 2, or a transitional/prelim stepping stone).

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Low scores narrow some doors, but they do not close your pathway to a meaningful residency and career. By targeting the right programs in the Great Lakes region, reinforcing your strengths, and presenting a cohesive story of resilience and growth, you can significantly increase your chances of a successful osteopathic residency match—even with a low Step 1 score or below average board performance.