Strategic Guide for DO Graduates: Matching with Low Step Scores in the Mountain West

Understanding What a Low Step Score Really Means for a DO Graduate

For a DO graduate in the Mountain West, a low USMLE Step 1 or COMLEX Level 1 score can feel like a major roadblock. Yet every year, applicants with below average board scores successfully match into solid programs—including in competitive areas like Colorado residency and other mountain west residency programs.

Before building a strategy, you need clarity on three key points:

1. What “low Step score” means in practice

   • Historically, below ~220 on Step 1 or substantially below the national mean on COMLEX Level 1 has raised concern.
   • With Step 1 now pass/fail, “low” is often interpreted as:
     • Multiple attempts or a failure before passing
     • Borderline pass in the context of other weak metrics
     • Low Step 2 CK / COMLEX Level 2-CE (now a major screening metric)
   • For DO graduates, COMLEX scores remain central, but many programs also look at Step 2 CK if taken.

2. How programs actually use scores
   Programs generally use board scores in three ways:

   • Initial screening tool (to manage high volume of applications)
   • Risk assessment (can you pass their board exams? ABIM, ABFM, ABS, etc.)
   • Tie-breaker among similarly qualified candidates

3. What matters more when scores are low
   Once you are past the initial filter, your:

   • Clinical performance (clerkship grades, Sub-I evaluations)
   • Letters of recommendation
   • Fit with the program and region (e.g., genuine interest in Mountain West practice)
   • Professionalism, communication, and work ethic
     often outweigh the raw score.

The key is to accept the score, control the narrative, and over-deliver everywhere else.

---

Choosing the Right Specialty and Region Strategy with Low Scores

Strategic targeting is the single most powerful lever for DO graduates matching with low scores—especially if you want to remain in or return to the Mountain West.

1. Be Honest About Specialty Competitiveness

Some specialties are extremely difficult to enter with low Step or COMLEX scores—even with a strong application. If your scores are significantly below average, you may need to adjust expectations or build a multi-year plan.

Very difficult with low scores (especially without strong backing):

• Dermatology
• Orthopedic surgery
• Plastic surgery
• Neurosurgery
• ENT
• Interventional radiology
• Some highly sought-after EM programs in major cities

More realistic (particularly for DO graduates with strong clinical performance):

• Family medicine
• Internal medicine
• Psychiatry
• Pediatrics
• Physical medicine & rehabilitation (PM&R)
• Pathology
• Transitional year / preliminary medicine as a bridge in some cases

If you are passionate about a more competitive specialty, consider:

• A research year
• A transitional / preliminary year to prove yourself clinically
• Targeting less competitive geographic regions first (potentially outside the Mountain West), then moving back after residency.

2. Leverage the Mountain West Advantage

The Mountain West (Colorado, Utah, Wyoming, Montana, Idaho, Nevada, New Mexico, and surrounding areas) has some important features:

• Fewer large academic centers than coasts

  • Many community-based or hybrid programs
  • Often more open to DO graduates and osteopathic residency match pathways

• High need for physicians in rural and semi-rural areas

  • Some programs prioritize applicants who express commitment to stay in the region
  • Lower applicant volume to certain rural programs can help offset low scores

• Regional loyalty matters

  • Having grown up, studied, or rotated in the Mountain West is a major plus
  • Programs want physicians likely to remain and serve their communities

Actionable tip:
Map every ACGME-accredited program in your desired specialty across the Mountain West. Identify:

• Community versus university-based
• Historically DO-friendly programs
• Programs in smaller cities or rural areas that may have fewer applicants

Focus on mountain west residency options where your DO background and regional ties are assets, not liabilities.

3. Be Realistic about Colorado vs. Broader Mountain West

Colorado residency positions—especially in Denver, Boulder, and Fort Collins—can be more competitive than other Mountain West states because of lifestyle appeal.

If your goal is specifically Colorado residency with a low Step 1 score or below average board scores:

• Apply broadly across all Colorado programs in your target specialty (including smaller or more rural sites)
• Simultaneously apply to neighboring states (Wyoming, New Mexico, Idaho, Montana, Utah, Nevada) to increase the likelihood of at least matching in the region
• Make it clear in your personal statement that your long-term goal is to build a career in the Mountain West, not just in Denver or a single city

---

Academic Recovery: Using Step 2 and COMLEX Level 2 to Your Advantage

For DO graduates, Step 2 CK and COMLEX Level 2-CE are now critical opportunities to offset a low Step 1 or Level 1 score. This is especially important for an osteopathic residency match in competitive subregions like Colorado.

1. Treat Step 2 / Level 2 as Your “Redemption Exam”

If you’ve already taken Step 1 or Level 1 and your score is low, you need a clear and disciplined plan:

• Target: improvement or clear strength

  • A strong Step 2 CK or COMLEX Level 2-CE can:
    • Reassure programs about test-taking ability
    • Signal growth and resilience
    • Shift focus away from earlier performance

• Timing:

  • Aim to take and receive scores before ERAS submission, especially if you believe you can show significant improvement.
  • If your practice exams are far below target, consult with your dean’s office or advisor about timing—delaying might make sense, but only if it results in a clearly stronger score.

2. Build a High-Yield, Structured Study Plan

Your approach must be tighter and more disciplined than it was for Step 1 or Level 1.

Key elements:

• Baseline assessment:
  • Use a practice exam (NBME for Step 2, COMSAE for COMLEX Level 2) to identify domains of weakness.
• Core resources (few, done well):
  • UWorld or Amboss QBank for Step 2
  • COMQUEST or TrueLearn for COMLEX Level 2
  • A single comprehensive review resource (e.g., OnlineMedEd, Boards & Beyond for Step 2 content review)
• Daily schedule:
  • 40–80 questions/day with focused review
  • Track missed question patterns in an error log
• Accountability:
  • Schedule weekly check-ins with a mentor, advisor, or study partner
  • Set clear weekly goals and adjust based on practice test performance

3. Address Test-Taking Barriers Head-On

Low scores are sometimes rooted in:

• Unrecognized learning disabilities
• Untreated anxiety, ADHD, or depression
• Poor test-taking strategies despite good knowledge

If any of these might apply:

• Seek a formal evaluation early (neuropsych testing, mental health care)
• Investigate whether you qualify for testing accommodations
• Consider a test-taking skills coach or tutoring program through your school or external services

Programs will view positively any documented pattern of improvement over time, particularly if reflected in:

• Step 2 / Level 2
• Clinical shelf exams or COMATs
• In-training exams (if applicable)

---

Maximizing the Rest of Your Application: Beyond the Score

Low Step or COMLEX scores shift the spotlight onto the rest of your application. Your goal is to build a cohesive, strengths-centered, region-focused narrative that overshadows the numbers.

1. Clinical Rotations and Sub-Internships (Sub-Is)

For DO graduates in the Mountain West, clinical performance is often the single most important factor after you clear basic score thresholds.

Priorities:

• Aim for honors or strong pass on key clerkships relevant to your specialty
• Target audition rotations (Sub-Is) at:
  • Programs in your desired region (e.g., Colorado, Utah, New Mexico)
  • DO-friendly programs with a history of interviewing DO graduates
  • Community-based departments if your scores limit you at big academic centers

During rotations:

• Arrive early, stay late, volunteer for tasks
• Be the person who is reliable, pleasant, and prepared
• Ask residents and attendings for specific, actionable feedback and apply it
• Let them see you as “a future intern on our team”

Strong rotation performance often translates directly into powerful letters of recommendation and interview invitations—even with below average board scores.

2. Letters of Recommendation (LoRs): Quality Over Title

Letters can make or break an application when your scores are low.

Aim for:

• 3–4 letters total, including:
  • At least one from your chosen specialty
  • At least one from a core rotation supervisor who worked closely with you
  • Ideally one from a Mountain West faculty member to emphasize regional ties

Stronger than “big-name, barely knows you” letters are:

• Letters that use specific examples:
  • “During a busy call night at our rural hospital, they stayed late to…”
  • “Their documentation and follow-through on consults were exemplary…”
• Letters that mention:
  • Work ethic
  • Team dynamics
  • Communication with patients
  • Improvement over time

How to get them:

• Request letters at the end of rotations while performance is fresh
• Provide your CV, personal statement draft, and talking points (including how you’ve grown from setbacks)
• Politely ask: “Do you feel you can write a strong, supportive recommendation for my residency applications?”

3. Personal Statement: Controlling the Narrative

When matching with low scores, the personal statement is your opportunity to contextualize—not excuse—your performance and highlight your strengths.

Consider structure:

• Opening:
  • A brief, specific clinical story or moment that led you toward your specialty or commitment to Mountain West communities
• Middle:
  • Demonstrate your strengths:
    • Patient-centeredness
    • Osteopathic philosophy and whole-person care
    • Commitment to underserved communities or rural medicine
  • Briefly and maturely address low scores (if needed):
    • Acknowledge them
    • Explain relevant context (without oversharing or blaming)
    • Emphasize what you learned and how you changed (e.g., study strategies, time management, wellness)
• Closing:
  • Reaffirm your desire to train and eventually practice in the Mountain West
  • Highlight what you bring to a program: reliability, resilience, teamwork, and a DO perspective

Avoid dwelling on the negative. Your statement should leave readers thinking, “This person will be a great resident,” not “This person has a low Step 1 score.”

4. CV, Experiences, and Osteopathic Identity

For DO graduates, your osteopathic identity can be a genuine asset, particularly in community and primary care–oriented mountain west residency programs.

Highlight:

• OMM/OMT experiences, especially with:
  • Rural or underserved patients
  • Musculoskeletal and pain populations
• Longitudinal community service, especially in Mountain West regions
• Leadership roles in:
  • Student organizations
  • Rural health initiatives
  • Telehealth or outreach projects

Show that you’re not just a candidate with a low Step 1 score—you are a well-rounded, service-minded future physician aligned with regional needs.

---

Application and Interview Strategy: Turning Weaknesses into Wins

After strengthening your academic and clinical profile, the next step is to apply smart and interview well.

1. Apply Broadly and Thoughtfully

For DO graduates with low Step or COMLEX scores, narrow application lists are risky.

Numbers to consider (will vary by specialty):

• Primary care (FM, IM, peds, psych):
  • Often 30–60+ programs, more if scores are significantly below average
• Moderately competitive specialties:
  • 60–80+ programs
• Very competitive specialties:
  • May require >80 applications plus a realistic backup specialty

Within the Mountain West:

• Apply to every DO-friendly program in your specialty
• Include rural and smaller community programs
• Don’t limit yourself only to high-demand cities or academic flagships

Outside the Mountain West:

• Include a safety net of geographically diverse programs
• Target regions known to be DO-friendly and less oversubscribed

2. Signal Genuine Regional Interest

Programs in the Mountain West want residents who will stay and serve.

You can demonstrate this by:

• Completing clinical rotations in one or more Mountain West states
• Highlighting regional ties:
  • Grew up in the region
  • Family here
  • Long-term interest in mountain or rural lifestyles
• Writing program-specific paragraphs in your personal statement for select programs (if allowed) or in ERAS “geographic preference” signaling
• Being explicit in interviews about:
  • Wanting to build a career in the region
  • Appreciation for the lifestyle and patient population
  • Interest in rural or frontier medicine (if applicable)

3. Prepare to Address Low Scores in Interviews

Interviewers may ask directly about your low Step 1 score or below average board scores. Prepare a concise, honest, forward-looking response:

A three-part structure works well:

1. Acknowledge and own it

   • “You’re right; my Step 1 score is below where I wanted it to be.”

2. Brief context and growth

   • “At that time, I underestimated how much test-taking strategy and structured review mattered. I’ve since changed my approach—using detailed question logs, weekly practice exams, and improved time management.”

3. Evidence of improvement + reassurance

   • “Those changes helped me significantly improve on Level 2 / Step 2 and on my clinical shelf exams. My performance on rotations and exams since then reflects the physician I am now—not just that one early score.”

Practice this response until it feels natural—calm, confident, and self-reflective, never defensive.

4. Showcase Fit and Strengths in the Interview

With scores no longer the focus, your interpersonal skills become paramount.

Emphasize:

• Teamwork: Examples of working well with nurses, residents, and staff
• Resilience: Handling difficult calls, long hours, or personal challenges
• Communication: Explaining complex conditions to patients at different literacy levels
• Osteopathic perspective: How OMM and whole-person care shape your approach

Ask smart questions about:

• Resident autonomy in rural rotations
• Community outreach in the Mountain West
• Support for DO residents (OMM clinics, board prep, etc.)

Programs should leave your interview thinking, “This applicant will be a safe, hardworking, teachable intern who fits our culture.”

---

Putting It All Together: A Sample Strategy for a DO Graduate in the Mountain West

To make these concepts concrete, consider this hypothetical scenario:

Profile:

• DO graduate from a school in the Mountain West
• Step 1: Pass (borderline)
• COMLEX Level 1: Below national mean
• Step 2 CK: Pending; practices near average
• Interested in: Family Medicine or Internal Medicine
• Goal: Match into a mountain west residency, ideally Colorado residency, but open to neighboring states

Step-by-Step Plan:

1. Pre-ERAS (6–9 months before application):

   • Intensively prep for Step 2 / Level 2 using a structured study plan and question banks
   • Complete 2–3 audition rotations:
     • One in Colorado (community FM or IM program)
     • One in another Mountain West state (e.g., New Mexico or Wyoming)
     • One at your home institution in your chosen specialty
   • Ask for letters of recommendation from attendings who can strongly endorse your clinical skills and work ethic

2. Application season:

   • Apply to 40–60+ programs in FM or IM:
     • All DO-friendly mountain west residency programs in your specialty
     • A mix of community and university-affiliated hospitals
     • Some outside the region as a backup strategy
   • Emphasize in your personal statement:
     • Commitment to rural and underserved care
     • Desire to remain in the Mountain West long-term
     • Growth from earlier board performance
   • Highlight regional ties in ERAS geographic preference and interviews

3. Interview season:

   • Prepare and practice a clear narrative about:
     • Why your specialty
     • Why Mountain West
     • How you’ve improved academically and clinically
   • Ask residents about:
     • DO inclusion and culture
     • Rural rotations or outreach in the Rocky Mountain region
   • Signal high interest politely to your top programs after interviews (thank-you emails, specific references to what you liked)

4. Rank list:

   • Rank programs based on:
     • Fit, training quality, and supportive environment (especially important for those with academic struggles)
     • Geographical priorities (Colorado residency near top if desired, but not at the expense of drastically fewer options)
   • Avoid “gaming” the list; rank where you truly want to train.

With this approach, low Step 1 score or below average board scores become just one part of your story, not its defining feature.

---

Frequently Asked Questions (FAQ)

1. Can I still match into a competitive specialty as a DO with low Step or COMLEX scores?
It’s possible but significantly more challenging. You’ll need:

• Strong Step 2 / Level 2 improvement
• Multiple audition rotations with stellar evaluations
• High-quality letters from leaders in that specialty
• Often a backup plan in a less competitive field
  For many DO graduates, aiming for a realistic primary specialty where they can thrive—often in primary care or hospital-based internal medicine—is a safer path, especially in the Mountain West where these physicians are highly needed.

---

2. Is it worth taking USMLE Step 2 CK if I already have COMLEX Level 2 as a DO?
In many cases, yes—especially if:

• Your COMLEX Level 1 score is low and you believe you can outperform on Step 2 CK
• You’re applying to programs or specialties that have historically favored USMLE
• You want to broaden your options beyond strictly osteopathic residency match opportunities
  However, don’t take Step 2 CK lightly. A second low score can worsen your situation. If you take it, commit to thorough preparation.

---

3. How many programs should I apply to if I have low scores?
It depends on specialty and how low your scores are, but as a DO graduate:

• Family medicine / internal medicine / pediatrics / psychiatry: often 40–60+ programs
• Slightly more competitive specialties: 60–80+
• Very competitive specialties: 80+ plus a serious backup specialty
  Prioritize quality and fit in your list, but when matching with low scores, volume does matter.

---

4. How do I know if a program is DO-friendly in the Mountain West?
Look at:

• Current and recent residents’ profiles (website, social media, FREIDA)
• Percentage of DO versus MD residents
• Historical match lists from your DO school (where have alumni matched?)
• Whether they explicitly mention COMLEX acceptance on their website
  If uncertain, you or your dean’s office can email their coordinator to ask whether DO graduates and COMLEX scores are fully considered.

---

By combining strategic specialty and regional targeting, strong clinical performance, Step 2 / Level 2 redemption, and a compelling story, DO graduates in the Mountain West can absolutely overcome low Step scores and build meaningful, successful careers—often right in the communities they care about most.