Strategies for DO Graduates: Matching with Low Step Scores in VA Residencies

Understanding the Landscape: Low Scores, DO Graduates, and VA Hospital Programs

For many DO graduates, a low Step 1 (or Level 1) score feels like a door slamming shut. When your dream is to train in VA residency programs and serve veterans, that anxiety can be even sharper. But a low or below average board score is not the end of your path to a VA residency—it just means your strategy must be sharper, earlier, and more intentional.

Key realities to ground your planning:

• VA residency programs are almost always affiliated with an academic medical center (often a university or large teaching hospital).
• Many programs welcome DO graduates and are familiar with osteopathic training paths.
• Selection at VA-affiliated programs is holistic but competitive, particularly for certain specialties and locations.
• A low Step 1 score or below average board scores will limit some options, but other options remain open—especially if you demonstrate value in other parts of your application.

Throughout this article, “board scores” refers to:

• USMLE Step 1 and Step 2 CK, and/or
• COMLEX Level 1 and Level 2-CE.

You can still make a strong case for yourself in the osteopathic residency match (or ACGME match for MD and DO graduates) and position yourself strategically for veterans hospital residency training.

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Step 1: Reframe Your Profile Beyond the Score

Before diving into tactics, clarify how programs actually view your application. Most VA residency programs use a holistic review model, especially as Step 1 has shifted to Pass/Fail, but numerical scores still matter for Step 2 CK and COMLEX Level 2-CE.

How Programs Weigh a Low Step or COMLEX Score

Programs care about:

1. Predictive value
   Scores predict performance on in-training exams and board certification exams. Low scores raise concern about:

   • Risk of failing future exams
   • Extra remediation needs
   • Program accreditation metrics

2. Context of your score

   • Was your Step 2 CK / Level 2-CE stronger than Step 1 / Level 1?
   • Did you improve significantly on retake?
   • Was there a documented life event or illness?

3. Evidence that you can succeed despite test struggles

   • Strong clinical evaluations, especially in core third-year clerkships
   • Honors or high passes in rotations
   • Strong letters, especially from VA faculty
   • Research or quality improvement work at a VA facility

Your job is to build a narrative: “I had a low exam score, I learned from it, and here is concrete proof that I can excel clinically and academically.”

DO-Specific Considerations

As a DO graduate, you face several additional questions from programs:

• Did you take USMLE as well as COMLEX, or only COMLEX?
• If only COMLEX, is your score convertible and understandable for MD-heavy programs?
• Are you pursuing osteopathic recognition programs, or are you comfortable in traditional ACGME residencies?

Many VA residency programs:

• Already have DO faculty and DO residents.
• Are familiar with interpreting COMLEX.
• May still value Step 2 CK heavily for comparison across applicants.

If you have a low Step 1 but have not yet taken Step 2 CK:

• Step 2 CK becomes your most important academic opportunity to change your trajectory.
• A strong improvement (e.g., jumping from low Step 1 percentile to middle or higher Step 2) can dramatically alter how committees view you.

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Step 2: Academic Recovery – From Low Score to Competitive Applicant

A single low board score does not define you, but you must proactively counterbalance it. Here’s how.

1. Strengthen Your Next Exam: Step 2 CK / COMLEX Level 2-CE

For applicants with low Step 1 scores or below average COMLEX Level 1, Step 2/Level 2 is often your redemption exam.

Strategic moves:

• Delay Step 2 CK or Level 2-CE until ready (within reason)
  Don’t rush into another low score. Work with:

  • Your school’s academic advisors
  • A remediation or learning specialist, if available

• Create a structured, high-yield study plan over 6–10 weeks:

  • Use one primary Q-bank (UWorld or COMBANK/COMQUEST).
  • Complete 70–80% of questions carefully, with detailed review.
  • Track weak systems (e.g., cardiology, renal, psych) and revisit them weekly.
  • Integrate dedicated time for OMM and osteopathic principles if taking Level 2-CE.

• Take practice exams seriously

  • NBME (for Step 2 CK) and COMSAE/COMAT tools (for COMLEX).
  • Aim for consistent improvement and only schedule the exam when practice results are at or above your target range.

If your first exam was significantly below average, your goal now is not “perfect”—it’s a clear upward trend that reassures programs you can pass boards and keep up with training demands.

2. Core Clerkship Performance: Where VA Programs Look Closely

Many VA residency programs pay close attention to:

• Internal Medicine
• Surgery
• Psychiatry
• Family Medicine
• Neurology

These rotations often have VA sites. Scoring Honors or High Pass, particularly at VA-affiliated hospitals, can speak louder than a low Step 1 score.

Tactics:

• Ask to rotate at VA-affiliated sites whenever possible.
• Show up early, stay late, volunteer for admissions and procedures.
• Ask for mid-rotation feedback and act on it.
• Request that feedback be documented in your evaluation where appropriate.

A strong track record of clinical performance tells VA programs: “In the actual hospital setting, I excel—even if standardized exams were a challenge.”

3. Consider an Additional Academic Year or Preliminary Position (Selective)

For some DO graduates with multiple low scores or high-risk profiles, an extra year can be beneficial:

• Transitional year (TY) or Preliminary year (Prelim Medicine or Surgery)
  At or near a VA-affiliated program, this can:

  • Demonstrate your ability to function at the intern level.
  • Generate new, strong letters, sometimes from VA faculty.
  • Provide a path to re-apply to residency with a stronger track record.

• Research year or VA fellowship (pre-residency)
  A dedicated year in outcomes research, quality improvement, or health services research at a VA medical center can:

  • Cement your commitment to veterans’ health.
  • Produce publications and posters.
  • Connect you with influential VA faculty advocates.

This is not necessary for everyone with a low score, but for those with multiple academic red flags, it can be a wise strategic investment.

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Step 3: Targeting the Right VA Residency Programs as a DO Graduate

Not all VA-affiliated residencies are equally accessible when you’re matching with low scores. Strategic targeting can make the difference between going unmatched and securing a position.

1. Understand VA Program Structures

Most VA residency experiences are offered through:

• University-based residencies where the VA is one of the main training sites.
• Community-based academic residencies with VA rotations.
• A limited number of VA-centered training programs with heavy veteran patient exposure.

You are rarely applying to the VA itself; you are applying to a residency whose curriculum incorporates VA hospital rotations.

2. Identifying DO-Friendly VA Residency Programs

For a DO graduate, you want to prioritize:

• Programs with current DO residents listed on their websites.
• Programs that explicitly mention:
  • “We welcome DO applicants”
  • “We accept COMLEX scores”
• Programs in regions known to be osteopathic-friendly (e.g., Midwest, parts of the South, certain community-based programs with VA affiliations).

Practical steps:

1. Go to FREIDA, program websites, and the VA’s Office of Academic Affiliations pages.

2. Make a spreadsheet with:

   • Program name, city, and VA affiliation
   • Presence of DO residents
   • Minimum USMLE/COMLEX requirements (if listed)
   • Average scores of matched residents, if available
   • Whether they accept COMLEX only

3. Flag:

   • Reach programs (slightly above your stats but DO-friendly).
   • Match-range programs (within your score range, DO-friendly).
   • Safety programs (below-average scores historically, strong DO representation).

Apply broadly to ensure you have enough programs that might look beyond your low Step score.

3. Specialty-Specific Realities at VA Sites

Your chances will be largely determined by specialty choice:

• More attainable (with low scores):

  • Internal Medicine
  • Psychiatry
  • Family Medicine
  • Neurology
  • Physical Medicine & Rehabilitation (PM&R), depending on region

• Highly competitive even with average scores:

  • Dermatology
  • Orthopedic Surgery
  • Plastic Surgery
  • Ophthalmology
  • Radiology (IR/DR)
  • Anesthesiology (varies by region)

If you have a strong desire to work in VA residency programs but have a significantly low Step 1 and Step 2 profile, favoring less competitive specialties can significantly improve your odds.

Consider a two-step path:

1. Match into a field like IM, FM, PM&R, or Psych with strong VA exposure.
2. Focus on subspecialty fellowships or VA staff roles later.

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Step 4: Building a VA-Focused Application Narrative

A veterans hospital residency program wants to know more than just your scores. They want to know: Why veterans? Why this system? Why you?

1. Leverage Genuine Veteran-Focused Experiences

You do not need military experience to be competitive, but VA committees respond well to:

• Volunteering with:
  • Veteran service organizations (VFW, American Legion, Team RWB, local VA volunteer services).
  • Homeless veteran shelters or veteran mental health programs.
• Research on:
  • PTSD, TBI, chronic pain, substance use disorders, or geriatric medicine in veteran populations.
• Clinical rotations:
  • At VA hospitals or clinics.
  • Rural health sites with a high veteran population.

If you lack direct VA experience, you can still show:

• Commitment to underserved populations.
• Work with older adults, trauma survivors, or individuals with complex chronic conditions.

2. Crafting Your Personal Statement for VA Programs

For a DO graduate with a low Step 1 score, the personal statement is your chance to:

• Acknowledge your test challenges briefly and professionally (if at all).
• Focus on your clinical strengths and growth.
• Emphasize your alignment with the VA mission: “To care for him who shall have borne the battle, and for his widow, and his orphan.”

Effective structure:

1. Opening vignette
   A patient story (preferably a veteran or similarly complex patient) that illustrates:

   • Your compassion
   • Your problem-solving
   • Your ability to connect

2. Core qualities
   Highlight traits VA programs seek:

   • Teamwork in interprofessional settings
   • Adaptability to resource constraints
   • Comfort with complex comorbidities
   • Cultural humility, especially with trauma and mental health

3. Academic setback (optional brief mention)

   • One to two sentences: “Earlier in my training, my Step 1 performance did not reflect my current capabilities. Since then, I have…”
   • Follow immediately with evidence of improvement: “Honors in core clerkships,” “Strong Step 2 CK performance,” “Positive faculty evaluations.”

4. Why VA / why this specialty
   Tie together:

   • Your DO training (holistic care, OMT where appropriate).
   • A commitment to long-term relationships and whole-person care.
   • Specific reasons the VA setting fits your values.

3. Letters of Recommendation: Prioritize VA and Academic Voices

For low Step or COMLEX scores, letters can carry outsized weight.

Aim for:

• At least one letter from a VA-based attending if at all possible.
• A letter from:
  • The core specialty you’re applying into (e.g., IM for Internal Medicine).
  • Someone who can speak to your clinical reasoning, reliability, and growth.

Ask letter writers explicitly:

• To comment on your readiness for residency.
• To mention your response to feedback and resilience if relevant.

When you approach VA faculty for letters:

• Provide a short CV.
• Highlight any special interest in veterans’ health or VA systems.
• Politely explain that you’re a DO graduate aiming specifically for VA residency programs, and that any mention of your fit for that environment would be especially helpful.

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Step 5: Interview Strategy and Post-Interview Advocacy

If you’re invited to interview despite a low Step 1 score or below average board scores, programs already see enough in you to consider you seriously. Your goal is to reinforce their confidence.

1. Addressing Low Scores If Asked

Interviewers may ask:

• “Can you tell me about your board performance?”
• “Is there anything in your academic record you’d like to explain?”

Respond with a brief, structured framework:

1. Own it without excuses
   “Early in medical school, I struggled with test-taking under pressure, and my Step 1 score reflected that.”

2. Context and insight
   “I realized I needed to improve my study strategies and test-day approach.”

3. Concrete changes

   • Shifted from passive reading to active QBank review
   • Sought mentorship or academic coaching
   • Implemented structured schedule and practice exam simulations

4. Evidence of improvement
   “These changes contributed to my improved Step 2/Level 2 score and consistent strong performance on clinical rotations.”

5. Reassurance
   “I’m confident these habits will help me succeed with in-training exams and board certification during residency.”

Avoid:

• Long justifications.
• Blaming others (school, exam style, unfair circumstances).
• Over-focusing on the score instead of the lessons learned.

2. Highlighting Your DO Background as an Asset

At VA hospital programs, DO training can be a significant advantage if you frame it well:

• Emphasize holistic care: Many veterans benefit from integrated approaches to chronic pain, mental health, and functional status.
• Discuss use of OMM/OMT where appropriate (especially in FM, IM, PM&R).
• Show comfort with:
  • Interprofessional collaboration
  • Whole-person care models
  • Motivational interviewing and behavioral health integration

3. Following Up: Targeted Communication Without Overdoing It

After interviews (especially at your top VA-affiliated programs):

• Send a brief, specific thank-you email:

  • Reference any meaningful discussion points.
  • Reiterate your interest in working with veteran populations.
  • Highlight one or two unique aspects of the program that align with your goals.

• If a program is truly your first choice, a post-interview communication (following NRMP rules) indicating strong interest can matter, particularly if your score profile is borderline.

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Practical Scenario Examples

To illustrate how these strategies come together, here are two realistic situations:

Scenario 1: DO with Low Step 1, Strong Step 2, Interested in VA Internal Medicine

• Step 1: 205 (pass), Step 2 CK: 235
• COMLEX Level 1 and Level 2: Average
• Honors in Medicine and Psychiatry, both at VA sites
• Two strong letters from VA attendings

Strategy:

• Target 40–60 Internal Medicine programs with VA affiliations, focusing on DO-friendly institutions.
• Highlight:
  • Step 2 CK improvement
  • VA clinical performance
  • Interest in veteran mental health and complex comorbid care
• Apply broadly, including some community programs with VA rotations and a few academic centers with known DO residents.

Scenario 2: DO with Below Average Scores Across the Board, Interested in VA Psychiatry

• Step 1: Pass with low performance report
• Step 2 CK: Slightly below national average
• COMLEX scores similarly modest
• Strong narrative of personal growth and interest in underserved mental health care
• Volunteer work at a VSO (Veteran Service Organization)

Strategy:

• Apply broadly to 60–80 Psychiatry programs, prioritizing community and regional academic programs with VA rotations and strong DO presence.
• Use personal statement to emphasize:
  • Commitment to trauma-informed care
  • Understanding of veteran-specific mental health issues
• If unsuccessful in matching, consider:
  • A research year at a VA mental health or PTSD program
  • Re-application with new letters and improved CV

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FAQs: Low Step Score Strategies for DO Graduates in VA Programs

1. Can I match into a VA residency program if I only took COMLEX (no USMLE) and my scores are below average?
Yes, it’s possible, but your options may be more limited. Some VA-affiliated programs accept COMLEX alone and are familiar with DO graduates; others strongly prefer or require USMLE scores. If you have time and your school permits, taking Step 2 CK and performing well can significantly broaden your options. Use program websites and email coordinators to confirm whether COMLEX-only applicants are considered.

2. Will a strong Step 2 CK or Level 2-CE score offset a low Step 1/Level 1 when applying to VA programs?
A significantly higher Step 2/Level 2 score is one of the most effective ways to mitigate low Step 1/Level 1 performance. Many VA residency programs place more emphasis on Step 2 because it correlates more closely with clinical knowledge and performance. You still need strong clinical evaluations and letters, but a clear upward trend reassures committees that you can pass in-training and board exams.

3. How important is direct VA experience for getting into a veterans hospital residency as a DO graduate with low scores?
Direct VA experience is very helpful but not strictly mandatory. Rotations at VA hospitals, VA-based research, or volunteering with veterans provide powerful evidence of fit and commitment—especially if your board scores are weaker. If your school does not offer VA rotations, seek out electives at VA-affiliated programs or engage with veteran-focused community organizations to build a veterans-centered narrative.

4. Should I address my low Step or COMLEX scores in my personal statement for VA programs?
If your low score is a major outlier or there is important context (e.g., documented health issues, major life event), a brief, factual explanation in your personal statement can be appropriate. Keep it to a few sentences and quickly pivot to what you learned and how you improved (e.g., better Step 2 scores, stronger clinical performance). Do not make the personal statement primarily about your test scores—focus on your passion for veterans’ care, your DO perspective, and your clinical strengths.

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By blending honest self-assessment, targeted academic recovery, VA-focused experiences, and strategic program selection, a DO graduate with low or below average board scores can still build a convincing case for a VA residency program. Your scores are one piece of the puzzle—not the entire picture. Use every other piece of your application to show who you are, how you’ve grown, and why you are ready to serve those who have served.