Essential Strategies for DO Graduates with Low Step Scores in EM-IM Residency

Understanding Your Situation as a DO Graduate with a Low Step Score

As a DO graduate aiming for an Emergency Medicine–Internal Medicine (EM IM combined) residency, a low Step 1 score or below average board scores can feel like a major obstacle. The EM-IM combined pathway is already relatively small and competitive; adding score concerns on top of that is understandably stressful.

Yet many DO graduates successfully match into emergency medicine internal medicine programs—or related pathways—even with a low Step 1 score or modest COMLEX/USMLE performance. Your outcome will depend less on the number itself and more on how you respond to it and strategically redesign your application.

This guide focuses on practical, evidence-informed strategies tailored to:

• DO graduates (recent or older)
• With a low Step 1 score and/or below average board scores
• Targeting Emergency Medicine–Internal Medicine combined programs, or flexible routes that keep both EM and IM career options open

You’ll learn how to:

• Accurately assess your competitiveness
• Use your osteopathic background as a strength
• Build a realistic, tiered residency application list
• Create compelling rotations, letters, and personal statements
• Apply “damage control” strategies specifically for low scores
• Keep EM-IM in play while protecting against going unmatched

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Step 1: Reframing and Analyzing Your “Low Score” in Context

Before planning, you need a precise understanding of how your scores will be viewed by EM-IM and related programs.

What Counts as a “Low Step Score”?

For EM-IM combined programs (where USMLE is frequently reviewed even for DOs), a low score often means:

• Step 1 (numeric era): < 220
• Step 2 CK: < 230, or lower than the program’s average matched score
• COMLEX Level 1/2: below national mean or first-attempt failures

But these are general benchmarks, not absolute rules. Programs assess scores in context:

• Trends (upward vs downward)
• First-time pass vs failures
• Strength of letters, SLOEs, rotation performance
• Class rank and clinical grades
• Research, leadership, and unique background

Action items:

1. List all your scores clearly:

   • COMLEX Level 1/2/3
   • USMLE Step 1/2 (if taken)
   • Note any failures, repeats, or substantial improvements.

2. Categorize your risk level:

   • Mild risk: Slightly below average, all first-time passes
   • Moderate risk: Clearly below average, but no failures and upward trend
   • High risk: Any failure, large gap between attempts, or persistently low scores

3. Talk with an advisor (EM or IM faculty, residency advisor, or EMRA/CORD advisor if available) and get an honest read on:

   • If EM-IM is still reasonable as a primary target
   • Whether EM-only or IM-only should be co-targeted
   • If a transitional year, preliminary IM, or categorical IM fallback plan is indicated

Understanding your starting point prevents unrealistic strategies and helps you prioritize your effort correctly.

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Step 2: Strategic Positioning for the EM-IM Combined Pathway

The EM IM combined route is small—only a limited number of programs and positions nationally—so every part of your application must be deliberate.

1. Understand How EM-IM Programs Think

EM-IM programs are looking for applicants who:

• Show genuine interest and insight into combined training
• Can thrive in high-intensity, cognitively demanding environments
• Handle significant workload and complexity
• Demonstrate resilience and reliability, especially under pressure

A low Step 1 score or below average board scores can raise concerns about:

• Standardized test-taking capability (especially for future boards)
• Ability to handle dense and broad internal medicine knowledge plus fast-paced EM
• Time management and study skills

Your strategy: directly address these concerns with evidence from other domains.

2. Clarify Your Career Vision

You need a clear, specific answer to:
“Why EM-IM instead of just EM or just IM?”

Effective examples:

• Desire to practice in academic settings, balancing ED shifts with inpatient medicine consults, ICU, or complex chronic disease management
• Interest in critical care, ED-ICU hybrid models, or hospital administration roles requiring dual expertise
• Commitment to safety-net hospitals, where continuity from ED through inpatient and beyond is crucial

Weak answers:

• “I couldn’t decide between EM and IM”
• “I want to keep my options open just in case”

Use your DO background to highlight:

• Holistic, patient-centered care that translates across EM and IM
• Interest in complex, multi-system disease management (IM) plus acute resuscitation (EM)
• Osteopathic training in whole-person, longitudinal thinking, which is invaluable for EM-IM roles in community and academic hospitals alike

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Step 3: Maximizing Clinical Rotations, SLOEs, and Letters

For applicants with lower scores, clinical performance and letters of recommendation are your single most powerful tools—especially in EM and EM-IM.

Prioritize Strong EM Rotations (and Consider EM-IM Sites if Available)

For a DO graduate interested in EM IM combined:

1. Complete at least two EM rotations:

   • One at your home institution (if available)
   • One away rotation at a program that either:
     • Has an EM-IM combined program, or
     • Is EM-friendly to DOs with a track record of matching DO graduates

2. If possible, secure:

   • An IM rotation at a strong academic or community IM program
   • Anything that showcases your ability in complex inpatient medicine (e.g., ICU, cardiology, hospitalist service)

Secure High-Impact SLOEs (Standardized Letters of Evaluation)

In EM and EM-IM, SLOEs often outweigh Step scores for interview decisions.

For low Step score applicants, you want SLOEs that explicitly say:

• You perform at or above the level of peers
• You are reliable, hard-working, and teachable
• Your clinical decision-making and work ethic offset any concerns from test scores

Actionable steps:

• On EM rotations, arrive early, stay late, and be visible to faculty who complete SLOEs.
• Ask explicitly:
  • “Do you feel you could write me a strong SLOE that would support my application to EM-IM or EM/IM?”
• If they show hesitation, do not use that letter as one of your primary SLOEs.

Choose Letter Writers Strategically

For EM-IM specifically:

• 2 SLOEs from EM faculty (ideally from core EM programs)
• 1 strong IM letter from an inpatient attending who directly supervised you
• Optional: an additional letter from a mentor, research supervisor, or EM-IM faculty member if you have one

What you want your IM letter to emphasize:

• Strong clinical reasoning, follow-through, and curiosity
• Your ability to manage medically complex patients
• Professionalism, compassion, and communication skills with patients and teams

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Step 4: Repairing and Offsetting Low Scores

Programs understand that not every applicant performs perfectly on standardized exams. Your goal is to demonstrate improvement and reliability moving forward.

1. Make Step 2 CK (or COMLEX Level 2) Your Redemption Arc

For many DOs—especially with Step 1 concerns—a strong Step 2 CK or Level 2 is crucial for matching with low scores.

• Aim for significant improvement compared to Step 1
• Use structured, high-yield resources (UWorld, Anki, NBME practice exams, COMSAE)
• Build a focused, time-blocked study schedule that you can share with faculty mentors if needed

Even if your Step 2 CK isn’t stellar, an upward trend and first-time pass help significantly.

2. Address Failures or Very Low Scores Carefully

If you had:

• A Step 1/Level 1 failure, or
• Very low first-attempt score followed by a retake

You must address this briefly and professionally—often in a short paragraph within your personal statement or an ERAS “additional information” section.

Focus on:

• What happened (concise, non-defensive, no extensive personal excuses)
• What you changed: Study strategies, time management, mental health support, practice exams
• Your improvement: Better performance on clinical rotations, Step 2/Level 2, or shelf exams

Programs are less concerned with the mistake than with your capacity for reflection and course correction.

3. Leverage Clinical Excellence as Counterweight

When matching with low scores, you need to overperform clinically:

• Ask residents and attendings for mid-rotation feedback and proactively fix weaknesses
• Volunteer for presentations, case conferences, or short teaching topics
• Be the student who reads on every case and follows up on outcomes

If SLOEs and IM letters repeatedly describe you as:

• “One of the hardest-working students we’ve had in years”
• “Among the top third of rotating students despite below average board scores”

You significantly reduce the impact of a low Step score.

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Step 5: Building a Smart Application Strategy as a DO with Low Scores

Your application list and overall strategy can matter as much as your metrics—especially for an osteopathic residency match candidate.

1. Be Realistic about EM-IM Program Numbers

EM-IM programs are few, with limited positions:

• They may risk-avoid applicants with any score red flags, especially if they receive many high-scoring applications.
• Most DO graduates with low Step scores should not apply exclusively to EM-IM programs.

A more resilient strategy:

• Apply to EM-IM combined programs that are DO-friendly and where you have a regional tie or rotation history.
• Simultaneously apply to:
  • Categorical EM programs
  • Categorical IM programs (especially those known to support critical care or hospital medicine interests)

This keeps your emergency medicine internal medicine career goals alive through multiple pathways:

• EM training with later IM/critical care fellowship
• IM training with EM-adjacent roles (ICU, acute care, hospitalist with ED cross-coverage in some communities)

2. Target Programs That Value DOs

As a DO graduate residency applicant, program choice is key:

• Look for programs with a history of matching DOs
• Prioritize places where EM or IM core faculty are DOs
• Consider community-based, university-affiliated, and safety-net hospitals, which may be more holistic in evaluation

Practical tools:

• Program websites and current resident bios
• EMRA/CORD program spreadsheets (if accessible)
• Talking with recent DO graduates from your school who matched into EM/IM/EM-IM

3. Apply Broadly—And Early

When matching with low scores:

• Submit ERAS on the first day applications open
• Apply to a wider range of programs and geographic locations than your peers with higher scores
• Avoid over-concentrating your list in one ultra-competitive region (e.g., only big coastal cities)

For moderate/high-risk applicants:

• Think in terms of:
  • 10–20 EM-IM and EM programs (if realistic)
  • 25–40 categorical EM programs (adjust by risk and advisor input)
  • 15–30 categorical IM programs (as a parallel or backup path)

Numbers will vary by year and your individual risk profile—use this as a conceptual framework, not an absolute rule.

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Step 6: Crafting a Compelling Story in ERAS and Interviews

Your narrative must unify your osteopathic training, low Step score trajectory, and EM-IM ambitions into a coherent, credible story.

Personal Statement Strategy for EM-IM with Low Scores

Key components:

1. Why EM and IM together?

   • Use a clinical story or pattern of experiences that show:
     • Love for acute emergencies
     • Deep interest in longitudinal or complex disease management

2. What you bring as a DO graduate

   • Emphasize:
     • Holistic, whole-patient mindset
     • Exposure to OMT (not because you’ll do OMT in the ED routinely, but because it shaped your diagnostic thinking and physical exam rigor)

3. Briefly acknowledge score concerns (if significant)

   • One short paragraph:
     • Acknowledge challenge, take responsibility
     • Highlight improvement and the skills you gained from overcoming this

4. Demonstrate resilience and reliability

   • Tell concrete stories of:
     • Managing high-acuity patients
     • Persevering through demanding rotations
     • Supporting colleagues and teams

ERAS Application Details

Maximize:

• Work and volunteer experiences that show:

  • Commitment to underserved or high-acuity populations
  • Longitudinal patient involvement (e.g., free clinics, continuity clinics)

• Research or scholarly work:

  • Case reports from ED or IM services
  • Quality improvement projects (e.g., sepsis pathways, readmission prevention)

If you lack traditional research, emphasize Q.I., teaching, or systems-based projects that align well with EM-IM’s focus on systems and continuity.

Interview Day: Addressing Low Scores Confidently

When interviewers ask, “Can you tell me about your board performance?”:

• Be honest, concise, and forward-looking:
  • Describe what changed in your approach (study habits, time management, seeking help)
  • Emphasize how those changes contributed to:
    • Stronger clinical performance
    • Better Step 2/Level 2 results (if applicable)
  • Avoid speaking negatively about your school, curriculum, or test format

What interviewers are really asking:
“Can we trust you to pass in-training exams and boards during residency?”

Answer with evidence of reliability, preparation, and consistency—not just reassurance.

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Step 7: Backup Plans and Alternative Pathways that Still Honor Your Goals

Not every DO graduate with low Step scores will match EM-IM or EM on the first attempt—but there are smart ways to stay on track.

1. Strong IM Pathway with EM/Acute-Care Focus

If EM-IM or EM doesn’t work out:

• Categorical Internal Medicine at a strong community or academic program can still lead to:
  • Critical care fellowship
  • Hospitalist roles with ED interactions
  • Administrative leadership in acute care or utilization management

During IM training, you can reinforce your EM-IM identity by:

• Doing ED electives as allowed
• Focusing on ICU, cardiology, pulmonary, nephrology (EM-relevant specialties)
• Engaging in QI projects that cross the ED-hospital boundary

2. Transitional Year or Preliminary Year

In some cases, a transitional year or preliminary IM year may:

• Let you prove yourself clinically
• Give you time to improve future exam performance
• Generate new, stronger letters and SLOEs

This is most appropriate if:

• You applied late
• You had unexpected failures or very low scores late in medical school
• Advisors believe another application cycle with stronger evidence would change outcomes

3. Consider EM-Adjacent or IM-Adjacent Paths

If repeated attempts at EM-IM/EM are not realistic, consider fields that keep you close to emergency and acute care:

• Hospital medicine (adult or combined adult/peds in some communities)
• Critical care medicine via IM
• Urgent care medicine after EM or FM training
• Palliative care or acute pain/recovery units within hospital systems

Your interest in emergency medicine internal medicine can still guide your career choices, even if the formal combined residency path changes.

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Frequently Asked Questions (FAQ)

1. I’m a DO graduate with a low Step 1 score but decent Step 2 CK. Can I still realistically match EM-IM?

Yes, it’s possible—but you’re in a riskier group and must be strategic:

• Use your stronger Step 2 CK/Level 2 as evidence of growth.
• Prioritize excellent SLOEs and IM letters that show you outperform your test scores clinically.
• Apply to a mix of EM-IM, categorical EM, and categorical IM programs, focusing on DO-friendly sites and regions.

Your odds improve significantly when your application demonstrates an upward trend, strong clinical performance, and a coherent EM-IM narrative.

2. Should I take USMLE as a DO if I already have low COMLEX scores?

It depends:

• If you already have low COMLEX scores and are unlikely to do meaningfully better on USMLE, adding another mediocre score won’t help.
• If mentors believe you can noticeably outperform your COMLEX on USMLE Step 2 CK (or already did so on Step 1), that can give you a boost, especially for EM-IM programs that favor USMLE numerics.

Discuss your situation with advisors familiar with both EM and IM program expectations in your target regions before deciding.

3. How many EM-IM programs should I apply to if my scores are below average?

Generally:

• Apply to all EM-IM programs where you are even remotely competitive, particularly those with a history of interviewing/matching DOs.
• Do not rely solely on EM-IM given its small size and high competition—pair it with a robust list of categorical EM and IM programs.

If your scores are significantly below national averages, EM-IM should be treated as a reach, not a safety, even with strong other metrics.

4. Do programs really read my explanation of a low Step score, or do they screen me out automatically?

Some highly competitive programs use strict cutoffs and may never see your explanation. However:

• Many EM, EM-IM, and IM programs—especially DO-friendly or community-based—review applications more holistically.
• In these settings, a brief, professional explanation plus clear evidence of improvement (better Step 2/Level 2, strong clinical evaluations) can keep you in contention.

This is why broad, targeted applications and upward performance trends matter so much when matching with low scores.

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Low Step or COMLEX scores do not define your potential as an Emergency Medicine–Internal Medicine physician, and they don’t automatically close the door on EM-IM combined training. As a DO graduate, you bring valuable strengths—holistic care, adaptability, resilience—that are highly relevant to this demanding but rewarding pathway. With careful strategy, honest self-assessment, and focused improvement, you can still build a career deeply rooted in both emergency medicine and internal medicine, even if your board scores started below where you hoped.