Essential Strategies for DO Graduates with Low Step Scores in Neurosurgery

Understanding the Challenge: Low Step Scores as a DO Applicant in Neurosurgery

Neurosurgery is one of the most competitive specialties in the residency match. As a DO graduate, you already know you’re navigating a steeper climb compared to many MD applicants, and adding a low Step 1 score, below average board scores, or even a failed attempt makes that hill feel even steeper.

Yet every year, applicants with imperfect metrics successfully match into neurosurgery residency, including those from osteopathic schools. The key is understanding:

• How programs think about scores
• What you can realistically change now
• Where you must compensate aggressively
• How to tell a compelling story that reassures program directors

This article focuses on low Step score strategies specifically for the DO graduate pursuing neurosurgery, with practical, realistic, and actionable steps.

We’ll address:

• How your scores will likely be interpreted
• Tactical steps to offset low scores
• Strategic use of research, sub-I’s, and networking
• Crafting your application narrative
• Backup planning that keeps your neurosurgical goals alive

Throughout, we’ll use terms like DO graduate residency, osteopathic residency match, neurosurgery residency, and brain surgery residency intentionally for clarity and to highlight considerations unique to osteopathic applicants.

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Section 1: How Programs View Low Scores in Neurosurgery

Before you design a strategy, you need to understand the landscape.

1.1. The reality of neurosurgery competitiveness

Neurosurgery typically has:

• High average Step/COMLEX scores for matched applicants
• Low overall match rates relative to many specialties
• A small number of total residency positions nationwide
• Strong emphasis on academic productivity, letters, and clinical performance

Programs are cautious because neurosurgery residency is long, demanding, and high-stakes. Poor early board performance raises concerns about:

• Passing later exams (Step 2 CK, Step 3, specialty boards)
• Handling the intense cognitive and workload demands
• Resilience and professionalism under pressure

This does not mean you’re disqualified; it means you must actively answer those concerns with other strengths.

1.2. What “low Step score” means in neurosurgery

“Low” is relative, but for neurosurgery:

• Below the typical matched average (often quite high) is “below average”
• A score near/below national mean is generally considered weak for this specialty
• A failed Step 1 attempt, a significant score drop on Step 2, or multiple COMLEX attempts raise red flags

If Step 1 was pass/fail for you, “low” usually refers to:

• COMLEX Level 1 or Level 2 scores below the mean
• A failed attempt on Step or COMLEX
• A Step 2 CK result clearly below typical neurosurgery standards

1.3. Additional scrutiny for DO applicants

As a DO graduate, you may face:

• Limited neurosurgery exposure at some osteopathic programs
• Fewer home neurosurgery departments or research pipelines
• Program bias towards MD applicants, especially at historically research-heavy institutions

Some programs are DO-friendly and have osteopathic residents or faculty; others rarely, if ever, interview DOs. Your approach must account for this reality by:

• Identifying DO-friendly neurosurgery residency programs
• Demonstrating equal or greater capability than MD peers in areas you can control (clinical, research, professionalism)

1.4. The good news: scores are one part of the picture

Neurosurgery programs heavily value:

• Sub-internship performance (sub-I’s/away rotations)
• Letters of recommendation from neurosurgeons
• Research productivity (particularly neurosurgery-related)
• Professionalism, drive, resilience, and “fit”
• A coherent, sustained narrative of commitment to neurosurgery

Your strategy is to shift the spotlight from your weaker metric (low Step / COMLEX) to your strengths, and to provide evidence that contradicts the fears raised by your score.

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Section 2: Academic Recovery – Mitigating a Low Step or COMLEX Score

You can’t change a low Step 1 score or a failed attempt—but you can change how programs interpret it by what you do next.

2.1. Crush Step 2 CK (and COMLEX Level 2)

If you haven’t taken Step 2 CK or COMLEX Level 2 yet, this is your single most powerful academic lever.

Goals:

• Demonstrate a clear upward trend (significantly stronger than your earlier exam)
• Reassure PDs that early issues are resolved and you’re ready for rigorous training
• Show mastery of clinical knowledge relevant to neurosurgery patients

Strategies:

• Build a purposeful, time-protected study plan (8–12+ weeks if your baseline is low)
• Use high-yield resources and question banks aggressively (UWorld, Amboss, etc.)
• Consider a formal commercial prep course or tutoring if:
  • You previously failed or underperformed despite strong effort
  • You struggle with standardized test strategies or timing
• Track progress objectively with practice exams and adjust your plan accordingly

If Step 1 was low but Step 2 CK is strong and above average, you can frame your story as:

“Once I transitioned to clinically oriented material and adjusted my studying, my performance improved significantly, as reflected in my Step 2 CK and COMLEX Level 2 scores.”

2.2. Excel in clinical rotations and sub-specialty electives

Your clinical evaluations are another measure of academic and professional capacity.

Focus especially on:

• Neurology, neurosurgery, ICU, trauma surgery, and other high-acuity rotations
• Comments on work ethic, teamwork, problem-solving, and patient care
• Concrete examples where you managed complex patients and showed leadership

Your goal is to collect evaluations that, when read by a program director, clearly say:

“This DO graduate is working at or above the level of our typical neurosurgery candidate.”

2.3. Use your transcript and MSPE to show growth

Ask your dean’s office how academic improvements and narrative comments appear in your MSPE (Dean’s Letter). You want:

• Recognition of improvement over time
• Clear notes about strong performance on clinical rotations
• No unexplained gaps or concerns going unaddressed

If there were legitimate hardships affecting your earlier exams (health, family crisis, etc.), discuss with your dean whether brief, factual context can be included.

2.4. Consider a research year or additional training selectively

For some, a dedicated research year or even a preliminary surgery year can:

• Provide time to build a strong neurosurgery-focused portfolio
• Allow you to obtain powerful letters from neurosurgical faculty
• Demonstrate academic capability beyond board scores

However:

• This is high-effort, high-cost, and not necessary for everyone
• It works best when you are integrated into a neurosurgery department with a track record of helping research fellows match

If your Step scores are dramatically below typical neurosurgery standards or you have multiple failures, a research year might be essential to become competitive.

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Section 3: Leveraging Your DO Background and Building a Competitive Neurosurgery Profile

Your identity as a DO graduate can be a liability in some spaces or a unique strength if you frame it strategically.

3.1. Emphasize unique strengths of osteopathic training

Highlight qualities your DO training often fosters:

• Strong patient-centered communication
• Holistic understanding of patient care
• Comfort with manual skills and procedural settings
• Resilience and adaptability from less resource-rich environments

You’re not “less than” an MD; you’re differently trained and can bring distinctive value to a neurosurgery team.

When you write or interview, consider examples such as:

• DO-based community rotations where you managed complex neurology/neurosurgery patients with limited subspecialty support
• OMM or MSK expertise that improved patient comfort and function pre-/post-op (without over-claiming OMM’s role in neurosurgery itself)

3.2. Target DO-friendly neurosurgery programs

Your residency list should strategically include:

• Programs with current or former DO neurosurgery residents
• Institutions that explicitly welcome DO applicants in program descriptions
• Community-based or hybrid programs that may be more flexible on scores compared to ultra-competitive academic powerhouses

Concrete actions:

• Review program websites, current resident rosters, and alumni lists for DOs
• Attend virtual open houses and ask politely if DOs have matched there before
• Reach out (professionally) to DO alumni from your school who matched into neurosurgery or other competitive specialties for insights

3.3. Align your research with neurosurgery and show productivity

For a neurosurgery residency or brain surgery residency application, research is highly valued:

• Aim for neurosurgery, neurology, neuro-oncology, neurocritical care, or spine-related projects
• Productivity matters:
  • Abstracts and posters at national meetings (e.g., CNS, AANS)
  • PubMed-indexed papers (even as middle author)
  • Quality improvement or outcomes projects within neurosurgery

If your board scores are low, research does not “erase” this, but it does:

• Signal seriousness and commitment
• Put you in close contact with neurosurgery faculty who can vouch for you
• Provide evidence of academic skills (data analysis, writing, persistence)

Tactical tip:

• Ask neurosurgery researchers: “What is a realistic project I can complete and submit within 6–12 months?”
• Focus on doable projects (retrospective chart reviews, case series, outcomes analyses) rather than overly ambitious but unfinished work.

3.4. Get strong, specific letters from neurosurgeons

In neurosurgery, letters of recommendation are pivotal—especially with below average board scores. You want at least:

• 2–3 letters from practicing neurosurgeons who know you well
• At least one from a program director or department chair if possible
• Letters that explicitly address:
  • Work ethic and grit
  • Clinical reasoning and operating room performance
  • Potential to thrive in neurosurgical training despite earlier academic bumps

You can help letter writers by:

• Providing a CV, personal statement draft, and a brief bullet list of:
  • Key patients you cared for together
  • Projects you worked on
  • Specific attributes you hope they can comment on honestly

For someone with a low Step 1 score, letters that say things like:

“Despite a lower than average Step score, I have no doubt this applicant will excel in a demanding neurosurgery residency and pass all required exams.”

can powerfully counterbalance concerns.

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Section 4: Strategic Use of Sub-Internships, Networking, and Application Framing

When your numbers aren’t perfect, your in-person impression and application narrative become even more critical.

4.1. Maximize sub-internships (sub-I’s)/away rotations

For neurosurgery, sub-I’s are a core part of the osteopathic residency match strategy, especially with lower scores.

Goals of your sub-I:

• Prove you function at the level of a strong future neurosurgery resident
• Earn top-tier letters that explicitly endorse you
• Demonstrate that your low Step score does not reflect your true clinical and cognitive capacity

On your rotation:

• Arrive early, stay late
• Be proactive, but not intrusive:
  • Offer to help with notes, pre-rounding, consent forms, dressing changes, and patient/family communication
  • Ask for feedback regularly and adjust immediately
• Read nightly on:
  • Cases you saw that day
  • Surgeries scheduled for the next day
  • Relevant neuroanatomy, pathophysiology, and management

If you know your Step scores are a concern:

• Do not open with an apology, but be ready to address it briefly if asked:
  • Accept responsibility
  • Explain what changed
  • Point to improved performance and concrete growth

4.2. Thoughtful networking that isn’t awkward or forced

Neurosurgery is a small field. Networking can:

• Help you identify DO-friendly and low-score-tolerant programs
• Gain informal advocates who might push your application onto the interview list
• Teach you how you are perceived and where you can evolve

Effective networking strategies:

• Attend neurosurgery conferences, both national and regional
• Participate in virtual open houses and Q&A sessions
• Email faculty brief, focused messages, such as:
  • Interest in joining a research project
  • Specific questions about their program’s training structure

Avoid:

• Oversharing about your “low Step score” in initial outreach
• Sending mass, impersonal emails
• Pressuring faculty to write letters or “get you in”

Instead, build authentic relationships over time through contribution (research help, clinical teamwork, thoughtful questions).

4.3. Framing your Step score in your personal statement and interviews

You don’t always have to discuss your low Step 1 score or below average board scores in your personal statement, but if there is a clear weakness (especially a fail), it’s often better to:

• Address it briefly, honestly, and maturely
• Avoid sounding defensive or making excuses
• Emphasize what you did to grow from the experience

Example framing (adapt, don’t copy):

“Early in medical school, I struggled with standardized test-taking and time management, which contributed to my below-average Step 1 performance. Recognizing that this could limit my ability to pursue neurosurgery, I sought structured mentorship, adjusted my study methods, and adopted a more disciplined approach to preparation. These changes led to a significant improvement in my clinical coursework, stronger performance on Step 2 CK and COMLEX Level 2, and more confidence in my ability to handle high-stakes evaluations. This experience ultimately strengthened my resilience and preparation for the demands of neurosurgical training.”

In interviews:

• Be ready for direct questions about your scores
• Practice a 60–90 second answer that:
  • Accepts responsibility
  • Explains specific changes you made
  • Ends by emphasizing your current trajectory and abilities

4.4. Application strategy: breadth, selectivity, and realism

With matching with low scores in neurosurgery, you must be both ambitious and realistic.

Application considerations:

• Apply broadly to neurosurgery programs, especially:
  • Programs with DO residents
  • Slightly smaller or less research-intensive institutions
  • Geographic areas where you have ties (hometown, med school)
• Consider dual-application strategies (more below)
• Do not self-eliminate from every top program, but prioritize where you have at least some chance based on:
  • Program DO history
  • Expected score ranges
  • Your research and clinical profile

Your goal is to get enough interviews; once you’re in the room (or on Zoom), your personal story and performance can outweigh your low score.

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Section 5: Backup Planning While Keeping Neurosurgery in Sight

Even with an optimized strategy, neurosurgery residency is not guaranteed for anyone, especially with low scores. You need a Plan B that you truly can live with, while keeping the door to a brain surgery residency career as open as possible.

5.1. Dual-application strategies

Some DO applicants with low Step scores choose to:

• Apply to neurosurgery as their primary dream, plus
• Apply to a more reachable specialty that:
  • Involves critical care, procedures, or neurology
  • Keeps them close to neurosurgical patients or teams

Possible secondary specialties (examples):

• Neurology (with eventual neurocritical care, stroke, or epilepsy focus)
• Physical medicine & rehabilitation (with spine or neurorehab focus)
• General surgery (with eventual focus in trauma or critical care)
• Anesthesiology (with neuroanesthesia or ICU focus)

This can be emotionally difficult, but it:

• Increases your overall odds of matching
• Puts you in a field where you might later collaborate with neurosurgeons
• Keeps alive the possibility of limited cross-over or fellowship work in neurosurgical domains (e.g., spine, pain, neurocritical care)

5.2. Using a preliminary or transitional year

For applicants who don’t match neurosurgery:

• A preliminary surgery year or transitional year can:
  • Provide additional time to strengthen your CV
  • Allow you to build relationships with neurosurgeons at your institution
  • Create opportunities for additional research and letters

However, this strategy:

• Does not guarantee a future neurosurgery spot
• Requires sustained neurosurgery involvement during the year (OR, call, research)

If you go this route, make it intentional, not just a holding pattern.

5.3. When to reconsider your specialty choice

Honest self-reflection is important. Consider:

• Are your low scores part of a bigger pattern of academic struggle despite maximal effort?
• Do you find clinical neurosurgery rotations energizing or overwhelmingly draining?
• Do your mentors—who know you well—believe you can realistically compete and thrive?

There is no shame in redirecting to another specialty where you can be exceptional and fulfilled. But if neurosurgery is genuinely your calling, and your mentors support this, then:

• A low Step score or even a failed attempt need not end the journey
• It does mean your path may be longer, more complex, and require extra persistence

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Section 6: Putting It All Together – A Stepwise Plan for the DO Graduate with Low Scores

To make this actionable, here’s a structured roadmap tailored to a DO graduate residency applicant in neurosurgery with below average board scores.

6.1. Immediate action checklist (0–3 months)

1. Assess your current profile honestly:

   • Step/COMLEX results, attempts, and trends
   • Clinical grades and narrative evaluations
   • Research output (CV-level, not just “in progress”)
   • Letters you can realistically obtain this year

2. Plan and execute Step 2 CK / COMLEX Level 2 strategy:

   • Create a high-yield content and question-based schedule
   • Seek tutoring or faculty support if prior performance was poor
   • Delay test date if absolutely necessary to avoid another weak score or fail

3. Identify neurosurgery mentors:

   • At your own institution (if present)
   • At nearby or affiliated centers
   • Through DO alumni networks and neurosurgical societies

4. Start or accelerate research involvement:

   • Prefer neurosurgery or neuro-adjacent projects
   • Aim for at least one tangible output (poster, abstract, or submission) before application

6.2. Intermediate steps (3–9 months)

1. Schedule sub-I’s/away rotations strategically:

   • Prioritize programs with DO residents or DO-friendly cultures
   • Consider one rotation at a research-heavy center if you have strong faculty advocates there

2. Refine your application narrative:

   • Draft your personal statement with an honest but concise explanation of your scores (if you choose to address them)
   • Emphasize:
     • Growth after early struggles
     • Concrete examples of neurosurgery commitment
     • Unique value as a DO graduate

3. Secure powerful letters of recommendation:

   • Ask neurosurgery attendings AFTER you have shown your capabilities on rotations and projects
   • Provide them with your updated CV and talking points

4. Network thoughtfully:

   • Attend conferences
   • Participate in open houses
   • Maintain professional email communication and follow-up

6.3. Application and interview season (9–15 months)

1. Apply broadly and strategically:

   • Prioritize DO-friendly neurosurgery residency programs
   • Consider dual-application to a realistic backup specialty if advised by trusted mentors

2. Prepare thoroughly for interviews:

   • Practice answering questions about:
     • Your low Step or COMLEX scores
     • Why neurosurgery, specifically
     • How you handle stress, long hours, and failure
   • Have several patient care and OR stories ready that illustrate your strengths

3. Signal professionalism and maturity:

   • Be on time, responsive, and courteous
   • Show humility without underselling yourself
   • Convey that you fully understand neurosurgery’s demands and still want the path

4. Rank list with both heart and head:

   • Rank every program where you could realistically train and be happy
   • Weigh DO-friendliness, culture, and support for residents with imperfect metrics

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FAQs: Low Step Score Strategies for DO Graduates in Neurosurgery

1. Is it still possible to match neurosurgery with a low Step 1 score as a DO graduate?
Yes, it is possible but significantly more challenging. Your chances depend on how low the score is, whether there are failures, and how convincingly you can demonstrate growth (strong Step 2/COMLEX Level 2, stellar sub-I performance, robust letters, and neurosurgery-focused research). DO applicants with low scores must be especially strategic about targeting DO-friendly programs and building strong neurosurgical mentorship.

2. Should I take both USMLE and COMLEX if I’m a DO applying to neurosurgery?
If you are early enough in your training, taking USMLE Step exams in addition to COMLEX often helps, as many neurosurgery programs are more familiar with USMLE scores. However, if you already have low USMLE scores, you should focus on demonstrating improvement with Step 2 CK and COMLEX Level 2. Do not take additional standardized exams unless you are confident you can perform substantially better; another low score may worsen your situation.

3. How much does neurosurgery research matter if my scores are below average?
Research is very important in neurosurgery and becomes even more critical when your board scores are weak. It does not erase a low Step score but can:

• Signal long-term commitment to the field
• Provide evidence of academic ability
• Connect you to neurosurgical mentors who can advocate for you
  Aim for tangible outcomes (posters, abstracts, papers) rather than merely listing “ongoing projects.”

4. When should I consider a backup specialty if I have low scores?
You should discuss this early with neurosurgery mentors and your dean’s office. If your scores are extremely low for neurosurgery standards or include multiple exam failures—and if your research and clinical neurosurgery exposure are limited—it may be wise to dual-apply or pivot to a related specialty (neurology, PM&R, general surgery, etc.). If you decide to dual-apply, make sure your backup choice is one in which you can envision a fulfilling career, even if neurosurgery ultimately doesn’t work out.

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A low Step score as a DO graduate aiming for neurosurgery residency is a serious obstacle, but not an absolute barrier. By combining academic recovery, targeted neurosurgery engagement, powerful mentorship, and honest self-reflection, you can give yourself the best possible chance to match—or, if needed, to pivot thoughtfully while staying true to your core interests in the neurosciences and surgical care.