Effective Strategies for DO Graduates with Low Step Scores in Residency

Understanding Your Starting Point as a DO Graduate with Low Scores

Applying to a Preliminary Medicine (prelim IM) year as a DO graduate with a low Step 1 score or below average board scores (USMLE and/or COMLEX) can feel intimidating—but it is far from hopeless. Many applicants successfully secure a preliminary medicine year despite being worried about matching with low scores.

Before crafting a strategy, you need a clear and honest assessment of where you stand:

• Clarify the data

  • What are your exact scores? (USMLE Step 1, Step 2 CK; COMLEX Level 1, Level 2-CE)
  • How far below the national mean are you?
  • Are your scores consistently low, or was there a single outlier exam?

• Identify red flags

  • Any fails on USMLE/COMLEX?
  • Any attempts on Step 2 CK or Level 2?
  • Extended time to graduation?
  • Academic probation or professionalism issues?

• Understand the context of Preliminary Medicine

  • Prelim IM positions are one-year, non-categorical internal medicine internships.
  • They are often used by:
    • Future specialists (e.g., neurology, anesthesiology, radiology, PM&R)
    • Applicants who want a strong clinical year to strengthen their profile
  • Prelim programs vary widely:
    • Some are highly competitive, tied to advanced specialties.
    • Others are service-heavy, less competitive, and more open to applicants with low Step scores or below average board scores, including DO graduates.

As a DO graduate, you bring assets that some allopathic graduates do not:

• Training in Osteopathic Principles and Practice (OPP)
• Often strong experience in community-based medicine
• Patient-centered communication and holistic care training

Your task is to leverage these strengths while strategically minimizing the impact of your weaker test performance.

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Step-Based Strategy: Turning Low Scores into a Manageable Risk

The key is to control what you can and present a trajectory that makes sense. Program directors know that not everyone is a perfect test-taker; what they worry about is future performance—especially on in-training exams and the ABIM boards.

1. If You Have Only Low Step 1 / Level 1

Many DO graduates have:

• A low Step 1 score or failed Step 1 on first attempt
• COMLEX Level 1 that is below average
• But no Step 2 CK yet, or it’s pending

For a prelim IM application:

• Step 2 CK (and Level 2-CE) becomes your most important opportunity to change the narrative.

Action Plan:

• Delay ERAS submission if possible until:
  • Step 2 CK and COMLEX Level 2-CE are taken and scored.
  • You can show upward trend or at least solid, “safe” passing scores.
• If you already know Step 1 is low, treat Step 2 CK as a make-or-break exam:
  • Dedicated 6–8 weeks of intense study.
  • Use UWorld IM questions clinically and conceptually (not just memorization).
  • Consider a tutor or structured prep course if you previously struggled with standardized tests.
• For DO applicants:
  • Sitting for USMLE Step 2 CK is usually beneficial for preliminary medicine because:
    • Many IM programs are more familiar with USMLE than COMLEX.
    • A reasonable Step 2 CK can soften the impact of a low COMLEX Level 1/2.

2. If You Have Low Step 2 / Level 2 as Well

If both Step 1 and Step 2 (or Comlex 1 and 2) are weak or below average:

• You are now working from a higher-risk profile, but matching into a prelim IM position is still feasible.
• Programs that may remain accessible:
  • Community hospital-based prelim IM tracks
  • Safety-net hospitals
  • Programs in less popular geographic locations
  • Hospitals with higher service demands but more flexible academic expectations

Action Plan:

• Double down on non-test-based strengths:
  • Strong clinical evaluations
  • Outstanding letters of recommendation (LORs)
  • Evidence of reliability, work ethic, and being easy to supervise
• Highlight any upward trend, even if scores remain below average:
  • Even modest improvement from Step 1 → Step 2 CK matters.
  • If Comlex Level 1 was borderline, but Level 2-CE is clearly passing and slightly better, emphasize this.

3. If You Have a Fail on Any Board Exam

A fail is a clear red flag, but not an automatic barrier to a prelim medicine year.

Action Plan:

1. Own it directly in your application:
   • Use your personal statement or a short explanation in ERAS:
     • Explain briefly:
       • What happened (no excuses, just context)
       • What you changed (study habits, health, environment, support)
       • How your subsequent performance improved
2. Show clear remediation:
   • Passed on the next attempt with better performance.
   • Completed a board prep course, or used a structured study plan under faculty guidance.
3. Reinforce reliability:
   • Very strong, specific LORs saying you are:
     • Punctual
     • Hardworking
     • Safe and conscientious
     • Capable of growth and insight

Program directors might take a chance on a DO applicant with a test failure if they see:

• Significant improvement
• Stable clinical performance
• Professionalism and strong recommendations

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Maximizing Your Application Components Beyond Test Scores

For a DO graduate with low scores targeting prelim IM, every other part of the application must be optimized. Programs will ask: “Will this person be safe, hardworking, and teachable on my wards?”

1. Letters of Recommendation: Your Most Powerful Tool

In preliminary medicine, letters of recommendation in Internal Medicine carry tremendous weight.

Whom to Ask

• Core IM rotation attendings who:
  • Worked with you closely for at least 2–4 weeks
  • Saw you on inpatient general medicine (ward) services
• Sub-internship (sub-I) attendings in:
  • Internal Medicine
  • Hospitalist services
• If possible, one letter from a program director or clerkship director

What Strong Letters Should Highlight

Ask letter writers to emphasize:

• Clinical judgment and safety in patient care
• Ability to prioritize tasks, follow up labs, and respond to changes
• Work ethic and willingness to help the team
• Communication skills with patients and nursing staff
• Emotional stability, humility, and ability to accept feedback
• Any explicit mention that:
  • “Despite below average board scores, [Name] functions at or above the level of their peers clinically.”

Practical Tip:
When you request a letter, say:
“Because my board scores are on the lower side, I’m hoping my letters can really speak to my strengths as a clinician and team member. If you feel you can write a strong letter highlighting that, I’d be grateful.”

2. Personal Statement: Reframing the Narrative

Your personal statement is not the place to obsess over scores. It’s a place to:

• Affirm your commitment to a demanding clinical year
• Show insight and resilience
• Highlight your fit with prelim IM specifically

Core elements to include:

• Why a preliminary medicine year makes sense for you:
  • Future specialty interests (e.g., neurology, radiology, anesthesiology, PM&R, ophthalmology, etc.)
  • Desire for strong foundation in inpatient medicine
• Brief mention (if relevant) of:
  • Test challenges
  • What you learned about yourself
  • The systems you built to improve performance (time management, study methods, wellness strategies)
• Most importantly:
  • Specific stories that show professionalism, dedication, and “doer” mentality on wards

Example angle:
“I have never been the fastest test-taker, but on the wards I am often the first to arrive and the last to leave. My preceptors have consistently commented on my reliability and thoroughness in patient care, which I believe are the qualities that matter most during a demanding preliminary year.”

3. CV and Clinical Experiences: Proving You Can Do the Work

You need to look like an applicant who lives in the hospital and thrives in patient care.

• Highlight:
  • Inpatient IM core rotations and sub-I
  • Any night float, cross-cover experience, or ICU exposure
  • Quality improvement (QI) or patient safety projects
  • Case reports or clinical poster presentations, especially in IM or your intended advanced specialty
• For DO graduates:
  • Include meaningful osteopathic manipulative medicine (OMM) or OMT activities only if they are relevant and you can clearly tie them to:
    • Pain management
    • Function
    • Holistic patient care
  • Avoid letting OMM overshadow your commitment to internal medicine fundamentals during this year.

4. Program Signaling and Preference

If ERAS preference signaling is available for prelim IM (this varies by year), use it with intent:

• Signal:
  • Programs that are DO-friendly (look at historical match lists, current residents)
  • Hospitals in regions you have ties to (home, family, med school region)
  • Programs that have a strong track record of placing prelims into advanced specialties later

Your goal is to look dedicated and realistic, not random.

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Targeting the Right Programs and Building a Smart Rank List

The biggest strategic error applicants with low scores make is aiming too high, with too few programs. For a DO graduate targeting a preliminary medicine year, volume and careful targeting matter.

1. Researching DO-Friendly and Test-Flexible Programs

Use these resources and methods:

• FREIDA & program websites

  • Look at:
    • Percentage of DO residents
    • Whether they accept COMLEX only or require USMLE
    • Number of prelim positions offered

• Current residents

  • Message DO residents in IM or prelim tracks on LinkedIn, specialty forums, or via your school’s alumni network.
  • Ask:
    • “Are there DO graduates with lower scores in your program?”
    • “Does the program value hard work and clinical performance over test scores?”

• Geographic considerations

  • Less competitive areas are often more open to matching with low scores:
    • Certain Midwest, South, and non-coastal programs
    • Smaller cities and community hospitals

2. Application Volume: How Many Programs?

For a DO graduate with a clearly low Step 1 score and/or below average board scores:

• Consider applying to:
  • 40–60+ prelim IM programs if:
    • Your scores are not catastrophically low
    • You have no exam failures
  • 60–80+ programs if:
    • You have an exam failure
    • Multiple below-average scores
    • Other red flags

This may sound like a lot, but prelim IM spots can be highly variable, and some programs fill largely with linked advanced specialty applicants.

3. Choosing Mix of Academic vs Community Programs

• Academic centers

  • Pros:
    • More structure, better teaching
    • Often involved in training advanced specialty residents
  • Cons:
    • Usually more competitive
    • Often score-sensitive

• Community programs / safety-net hospitals

  • Pros:
    • Often more open to DO graduates and matching with low scores
    • Heavy clinical exposure; lots of responsibility
  • Cons:
    • Potentially less formal teaching
    • More service-heavy schedules

As a DO graduate with low scores, lean your list toward:

• Community and hybrid academic-community hospitals
• Programs that explicitly mention DOs and COMLEX
• Hospitals where prelim interns are treated similarly to categorical IM interns

4. Building a Rank List That Reflects Reality

On your rank list:

• Put any “reach” academic programs that interviewed you at the top if you genuinely like them.
• But fill the rest with:
  • Programs where:
    • The interview day emphasized work ethic and teamwork
    • Faculty seemed open and supportive
    • Residents looked like they had diverse backgrounds (including DOs)

Remember:

• It is far better to match into a busy, less glamorous prelim IM program than to go unmatched trying only for top-tier hospitals.
• Your prelim year is a stepping stone. Surviving and thriving clinically is more important than prestige.

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Interview and Post-Interview Strategy: Show Them You’re the Safe Bet

Once you land interviews, your low Step 1 score or below average board scores become less central. You are now being evaluated as a future colleague.

1. How to Address Low Scores in Interviews

If they ask directly:

• Answer confidently, briefly, and with insight.

Example Response: “I struggled with standardized testing early in medical school, which contributed to my lower Step 1 score. I realized my approach wasn’t effective, so I sought help from our learning specialists, changed my study strategies, and built more consistent daily routines. While my scores still aren’t stellar, I improved on Step 2 CK, and my clinical evaluations have been consistently strong. I’m very comfortable managing patients on the wards, which I believe is the core of a good preliminary year.”

Key elements:

• Acceptance of responsibility
• Description of concrete changes
• Emphasis on clinical performance

Avoid:

• Blaming the exam, school, or external factors.
• Over-explaining or sounding defensive.

2. Emphasizing Your Strengths as a DO Graduate

In interviews, highlight:

• Your osteopathic training’s focus on:
  • Whole-person care
  • Communication and patient rapport
• Examples where:
  • You coordinated with multidisciplinary teams
  • You went above and beyond for a patient
  • You responded well to stressful clinical situations

Make it clear that:

• You understand prelim IM is intense, often thankless work.
• You are ready to work hard, be teachable, and support the team.

3. Post-Interview Communication

For programs that felt like a good fit (especially realistic ones):

• Send brief, professional thank-you emails to:
  • Program director
  • Key faculty interviewers
• Reiterate:
  • Genuine interest in their program
  • Appreciation for their openness to DO graduates
  • Recognition of their strong clinical training environment

Example: “After speaking with you and your residents, I’m even more convinced that your program’s strong inpatient medicine training and supportive culture would be an excellent fit for my goals. I would be honored to train as a preliminary medicine intern at your institution.”

Do not:

• Overpromise (“I will rank you #1”) unless you truly mean it and it’s permitted by NRMP guidelines.
• Send multiple repetitive messages.

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Using the Preliminary Year to Set Up Your Next Step

Your preliminary medicine year is not just a checkbox. For a DO graduate with low scores, it is an opportunity to rewrite your professional narrative.

1. Performance During Prelim Year

Once matched, the most important things you can do:

• Show up early, be prepared, and know your patients better than anyone else.
• Communicate effectively with:
  • Nurses
  • Consultants
  • Patients and families
• Seek and act on feedback:
  • Ask seniors, “What’s one thing I can do better this month?”
  • Implement suggestions immediately.

Program directors often remember:

• The intern who always responded promptly
• The one who volunteered to help others
• The intern trusted with sick patients overnight

If you had matching with low scores to get into prelim IM, your clinical reputation now becomes more important than any test result for your future applications.

2. Planning for Your Advanced Specialty or Categorical IM

While you’re doing your preliminary medicine year, consider:

• If your goal is an advanced specialty (like anesthesiology, neurology, radiology, PM&R, etc.):

  • Meet early with:
    • That specialty’s program director at your hospital
    • Faculty mentors in your target field
  • Let them know your path and ask:
    • “What would I need to demonstrate this year to be a competitive applicant from here?”

• If you might want to convert to categorical IM:

  • Work especially hard on IM rotations.
  • Make sure IM faculty know you, and know that IM is a serious option.
  • If a categorical spot opens due to attrition, a strong prelim can sometimes be offered that spot.

3. Letters and Future Applications After Prelim Year

For future applications (advanced or categorical):

• Secure new LORs from:
  • Program director of your prelim IM year
  • Senior IM attendings who worked with you extensively
• These letters can powerfully say:
  • “Despite low board scores, Dr. [Name] functioned as one of our top interns, and I would gladly hire them again.”

This is how you transition your identity from:

• “Applicant with low Step scores” to
• “Dependable intern and strong clinician who overcame early obstacles.”

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FAQs: Low Step Score Strategies for DO Graduates in Preliminary Medicine

1. As a DO graduate, do I really need USMLE for a preliminary medicine year?

You don’t always need USMLE, but it often helps. Many prelim IM programs are more familiar with USMLE than COMLEX. If your COMLEX scores are low but you can achieve a solid Step 2 CK, that can mitigate your earlier performance. However, if you historically have severe test anxiety or repeated low scores, adding another exam may not be wise. Discuss this with your school’s dean or advisor.

2. Can I still match into a prelim IM program with a failed Step or COMLEX attempt?

Yes, it is possible, especially in community or DO-friendly programs. You must:

• Demonstrate clear improvement on the retake.
• Have strong IM clinical evaluations and letters.
• Provide a brief, honest explanation of the failure and what changed. Programs will take a chance on someone who shows growth, insight, and reliability.

3. How many prelim medicine programs should I apply to with below average board scores?

For a DO graduate with below average board scores, consider:

• 40–60+ programs if you have no fails and some strengths (good letters, solid clinical record).
• 60–80+ if you have fails or multiple red flags. A wide net improves your chances, especially when targeting less competitive regions and DO-friendly institutions.

4. Is a preliminary medicine year worth it if my long-term goal is a different specialty?

In many cases, yes. A preliminary medicine year can:

• Provide strong inpatient experience valued by nearly all specialties.
• Help you build a new track record of clinical competence and professionalism.
• Offer new letters of recommendation that override the negative weight of low scores. However, you should be realistic about your intended advanced specialty’s competitiveness. For very competitive specialties, a prelim year alone may not be enough to offset low scores, and you may need additional steps (research, extra training, or reassessing specialty choice).

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By understanding the landscape, targeting the right programs, and relentlessly strengthening every non-test component of your application, you can absolutely secure a preliminary medicine year as a DO graduate with low scores—and use that year as a powerful springboard for the rest of your career.