Essential Strategies for DO Graduates with Low Step Scores in Texas

Understanding the Challenge: Low Step Scores as a DO Graduate in the Texas Triangle

If you are a DO graduate targeting residency programs in the Texas Triangle (Houston, Dallas–Fort Worth, San Antonio, and surrounding areas) and you’re worried about a low Step 1 score, you are not alone. Many strong candidates have numerical weaknesses on their applications—whether that’s a low Step 1, a below average COMLEX Level score, or a performance dip on Step 2.

The key is this: a low score is a liability, but it is not a verdict. Especially as a DO graduate, you can still match into solid Texas residency programs by being deliberate, strategic, and realistic.

In this article, we’ll walk through:

• How Texas programs actually view low scores and DO applicants
• Which specialties and program types are most realistic with below average board scores
• How to craft a competitive application targeted to Houston, Dallas, and San Antonio residencies
• Concrete strategies to offset low Step/COMLEX performance
• How to build a smart rank list and backup plan within the Texas Triangle and beyond

Throughout, we’ll specifically reference DO graduate residency options and strategies for matching with low scores in the Texas market.

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How Texas Programs View Low Scores and DO Applicants

The Texas Triangle Landscape for DO Graduates

The Texas Triangle contains a dense cluster of training sites:

• Houston: Large academic centers (e.g., UT Houston/McGovern, Baylor), plus community and county programs
• Dallas–Fort Worth: UT Southwestern, large community systems, private hospital-based programs
• San Antonio & Austin corridor: UT Health San Antonio, Dell (Austin), plus smaller community programs and new residencies expanding across Central Texas

Historically, DO graduates have had varying degrees of acceptance in Texas. Some academic programs are more USMD-heavy, while many community-based programs and newer training sites are open to and actively recruit DO residents. The key is knowing which types of programs are more realistic for a candidate with a low Step 1 score.

What Counts as a “Low” Score?

While Step 1 is now pass/fail, many DO applicants still worry about:

• A borderline pass or prior low numerical Step 1 score
• Below average Step 2 CK or COMLEX Level 2-CE
• Failed attempts on Step or COMLEX

Programs in Texas (like elsewhere) commonly apply score filters. While exact cutoffs vary, reasonable approximations for more competitive vs. more holistic programs might be:

• Highly competitive academic programs: Often want above-average Step 2 (and solid COMLEX if used) and may screen out for failures
• Mid-tier and community programs: More flexible, may consider a DO with a low Step 1 score or below average Step 2 if other parts of the application shine
• Newer or smaller programs: Often the most open to applicants with numerical weaknesses, especially if you show a strong connection to Texas and their specific community

DO vs MD: Does Being Osteopathic Help or Hurt?

As a DO graduate:

Challenges:

• Some Texas university-based programs lean heavily toward USMD applicants
• Historically fewer DO grads matched into certain flagship academic institutions

Advantages and neutral factors:

• Texas has a rapidly growing number of DO-friendly and DO-led programs
• Many programs now accept COMLEX alone or view it alongside USMLE
• Your osteopathic training, OMM skills, and whole-person care orientation can be real selling points, especially in community and primary care–oriented residencies

The takeaway: with low scores, your most realistic path is typically DO-friendly, community-oriented, and newer programs, particularly in internal medicine, family medicine, psychiatry, and certain prelim or transitional year slots in the Texas Triangle.

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Choosing Realistic Specialties and Programs with Low Scores

Step One: Honest Self-Assessment

Before you can target Texas residency programs effectively, you need a clear-eyed review of:

• Board exam profile:
  • Step 1: pass/fail or old numerical score
  • Step 2 CK score and any failed attempts
  • COMLEX Levels and attempts
• Clinical performance:
  • Core clerkship grades and narrative comments
  • Any red flags (low evaluations, professionalism concerns)
• Research and scholarly work
• Geographic ties to Texas:
  • Did you grow up there? Family in Houston, Dallas, or San Antonio? Rotations in Texas?

This helps determine where you are on the spectrum:

• Mild concern: Slightly below average Step 2/COMLEX, passing on first attempt
• Moderate concern: Clearly low or borderline Step 2/COMLEX, or one failed attempt with improvement
• High concern: Multiple failed attempts, very low scores, or multiple academic issues

The more serious the concern, the more aggressively you need to stack other strengths and broaden your program list.

Specialties That Are More Forgiving of Low Scores

For DO graduates with below average board scores aiming to stay in the Texas Triangle, the following specialties tend to be more realistic:

• Family Medicine (multiple DO-friendly programs across Houston, Dallas–Fort Worth, San Antonio, and surrounding areas)
• Internal Medicine (especially community-based and DO-led programs; academic IM may still be competitive)
• Psychiatry (growing demand, though still competitive in top locations; community and newer programs more open)
• Pediatrics (dependent on program; community programs often more flexible than big-name academic centers)
• Transitional Year / Preliminary Medicine (as stepping stones, though some are surprisingly competitive)

More competitive specialties—like dermatology, orthopedic surgery, plastic surgery, ophthalmology, and some radiology programs—are very difficult to enter with low scores, especially if you’re limited geographically to the Texas Triangle.

Targeting Texas Programs Strategically

Within the Houston–Dallas–San Antonio corridor, consider these broad guidelines:

More Score-Sensitive (often harder with low scores):

• Flagship university-based programs in highly desirable urban centers
• Programs that receive thousands of applications per year
• Residencies in the most competitive specialties (e.g., ortho, derm, ENT)

More DO- and Low-Score-Friendly:

• Community hospitals affiliated with, but not dominated by, a large academic center
• Newer residency programs (fewer years of graduates, building reputation)
• Programs led by DO program directors or core faculty
• Safety-net or county-type hospitals with strong service needs

Action steps:

1. Use resources like FREIDA, program websites, and NRMP/ERAS data to identify DO-friendly Texas residency programs and note:
   • Whether they accept COMLEX alone
   • Whether they list specific score cutoffs
2. Talk to recent DO alumni from your school who matched in Texas, especially in Houston, Dallas, or San Antonio, to learn:
   • Which programs were open to low Step 1 or below average Step 2 scores
   • Which PDs truly value osteopathic training

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Building a Competitive Application Around a Low Score

Even if your scores are not ideal, you control many powerful variables. Your goal is to make reviewers say, “Yes, the score is lower than we usually take, but this applicant is clearly an asset to our program.”

Maximizing Clinical Rotations, Especially in Texas

For DO graduates, audition rotations (away rotations or sub-internships) in Texas are one of the most powerful tools for overcoming low Step or COMLEX performance.

Prioritize:

• Acting Internships (AIs)/Sub-Is in your target cities:
  • An inpatient internal medicine month in Houston or Dallas
  • A family medicine or psychiatry rotation at a community-based Texas program
• Rotations at programs where you realistically want to match, not just prestige sites

During these rotations:

• Show up early, stay late, and be the most reliable member of the team
• Ask for mid-rotation feedback and adjust promptly
• Seek opportunities to present a short teaching session or a patient case
• Express interest in the program and the Texas community authentically

A stellar evaluation and a strong letter from a Texas rotation can weigh heavily against a low numeric score.

Letters of Recommendation (LORs) that Work for You

High-impact LORs can significantly offset doubts about matching with low scores:

• Aim for 3–4 strong letters, including:
  • 1–2 from core specialty attendings (IM letters for IM, FM for FM, etc.)
  • At least one from a Texas rotation if possible
  • Ideally one from a program director or department chair

LORs should emphasize:

• Your clinical reasoning and improvement since boards
• Your work ethic, reliability, and teamwork
• Any specific stories that show resilience (e.g., how you responded after a disappointing board score)

Crafting a Personal Statement that Confronts and Reframes Low Scores

Your personal statement is not the place to write a confessional essay about your test anxieties—but it is a place to strategically address the issue if needed.

Use it to:

• Briefly acknowledge the score or failure if it appears as a major outlier
• Provide concise context without making excuses (e.g., health issues, caretaking responsibilities), only if honest and relevant
• Emphasize:
  • Concrete changes you made to improve study habits
  • Evidence of growth (e.g., improved clinical performance, better subsequent scores, research output)
  • Your commitment to serving Texas patients and communities

For DO graduates, also highlight:

• Your osteopathic perspective—whole-person care, OMM, primary care orientation—especially if applying to fields like family medicine, IM, PM&R, or psychiatry.

Leveraging COMLEX and USMLE Data

As a DO graduate, your board profile might include COMLEX only, both COMLEX and USMLE, or a mixed picture. With a low Step 1 score or below average Step 2 CK:

• If Step 2 is stronger than Step 1, highlight this as evidence of improvement.
• If COMLEX is significantly better than USMLE (or vice versa), emphasize:
  • Your best performance in your CV and in any brief explanations.
• If you have a failed attempt but passed on the next try:
  • Note the improvement, change in study strategy, and what you learned from the process.

Where possible, have a mentor or dean’s letter (MSPE) provide supportive context to program directors.

Enriching the Rest of Your Application

Other components that matter more for DO graduates with low scores:

• Clinical grades and narratives: Honors or strong evaluations in key clerkships (IM, FM, psych) demonstrate performance beyond test-taking.
• Research and scholarly work: Especially if related to:
  • Underserved Texas populations
  • Your chosen specialty
• Service and leadership:
  • Free clinics, especially those serving Texas communities
  • DO student leadership roles
  • Community outreach in Houston, Dallas, or San Antonio if you’ve spent time there

These elements all contribute toward the story: “I may have a low Step 1 score, but I’m a high-value resident for your program and your patient population.”

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Application Strategy: Numbers, Timing, and Texas-Specific Tactics

How Many Programs Should You Apply To?

With a low Step 1 score or overall below average board scores, underapplying is risky—especially if you limit yourself to the Texas Triangle.

Approximate guidelines (for core specialties like IM/FM/psych/peds) for a DO graduate with low scores:

• If you are geographically flexible (nationwide):
  • 60–100+ programs in your chosen specialty
• If you are heavily Texas-focused but open to other states:
  • 40–70 programs, with 15–30 in Texas and the remainder in other DO-friendly states
• If you are strongly restricted to the Texas Triangle only:
  • Consider:
    • Applying very broadly within the Triangle across multiple specialties (e.g., IM, FM, prelim)
    • Adding nearby Texas or regional programs outside Houston–Dallas–San Antonio (e.g., smaller cities)
    • Having a clear backup plan (see below)

Timing: Use Step 2/Level 2 Wisely

For DO graduates with low Step 1:

• Take Step 2 CK/COMLEX Level 2 early enough so that:
  • You can get scores back before ERAS submission.
  • You have time for a retake if you fail or perform much worse than expected.
• If you expect Step 2 to be much stronger, consider:
  • Timing your exam so the score is available right at the start of application season to counterbalance Step 1.

Signaling Interest and Geographic Fit

Programs in Houston, Dallas, and San Antonio may screen heavily on board scores—but many also care deeply about geographic commitment and likelihood that you will rank them highly.

Ways to demonstrate this:

• Address Texas connections clearly in your personal statement and ERAS geographic preferences.
• In interviews and correspondence, be specific about:
  • Family in the Texas Triangle
  • Long-term plan to practice in Texas
  • Interest in serving the specific patient populations in that city or county
• Participate in virtual or in-person open houses for Texas residency programs and mention your attendance in follow-up emails.

Interview Strategy When You Have Low Scores

When invited to interview:

• Prepare a brief, practiced explanation of your low Step 1 or below average board scores:
  • Own the result; do not blame others.
  • Emphasize what you changed and how you grew.
  • Highlight concrete improvements: better Step 2, strong clinical evaluations, etc.
• Reframe the narrative:
  • “My scores taught me how I learn, how to manage setbacks, and how to advocate for myself and my patients.”
• Focus heavily on:
  • Your fit with the program’s mission
  • Your desire to train and stay in Texas
  • Your strengths in teamwork, communication, and patient care

Programs that still invite you despite low scores are, by definition, open to your overall profile. Your job is to confirm their impression that you’re a resilient, teachable, and committed future resident.

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Backup Plans and Long-Term Strategy If You Don’t Match in Texas

Even with excellent strategy, every year some DO graduates with low scores do not match into their first-choice specialty or region. You should plan now what you’ll do if you do not match in the Texas Triangle.

Broaden Scope: Beyond Houston–Dallas–San Antonio

If you’re truly committed to training in Texas, be open to:

• Smaller cities and non–Texas Triangle residency programs within the state
• Rural or semi-rural community programs that are highly DO-friendly
• Programs affiliated with large systems but located in less competitive geographic areas

If you’re committed to a specialty but flexible on location, consider:

• A national search for DO-friendly IM/FM/psych/peds programs
• Regions with historically higher DO representation (e.g., certain Midwest and Southeast states)

Post-Match Options for Low Scores

If you do not match:

1. SOAP (Supplemental Offer and Acceptance Program):

   • Many unfilled programs during SOAP are community-based and DO-friendly.
   • Be ready to pivot specialties if needed (e.g., from IM to FM or prelim).

2. Preliminary or Transitional Year:

   • Complete a prelim medicine or surgery year, then:
     • Strengthen your application with excellent evaluations and updated LORs
     • Reapply the next cycle, possibly broadening your geographic range

3. Research or Clinical Gap Year:

   • Join a research team at a Texas institution or elsewhere.
   • Continue clinical exposure (scribing, clinical assistant roles, volunteer clinics).
   • Retake any remaining board exams to show improved performance.

Throughout, maintain:

• Consistent clinical involvement
• Updated contact information and CV
• Ongoing mentorship from faculty who understand the DO graduate residency landscape

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Frequently Asked Questions (FAQ)

1. Can I still match into a Texas residency program with a low Step 1 score as a DO graduate?

Yes, it’s possible, especially into DO-friendly, community-based, and primary care–oriented programs in internal medicine, family medicine, psychiatry, or pediatrics. Top-tier academic programs in Houston, Dallas, and San Antonio may be tougher, but many community and newer programs are open to DO applicants with below average board scores if the rest of the application is strong—solid clinical evaluations, strong letters, genuine Texas ties, and a compelling personal story.

2. Should I take USMLE if I already have COMLEX and low board scores?

It depends. If your COMLEX scores are already low, taking USMLE may not help unless you are confident you can significantly outperform your COMLEX. Many DO-friendly Texas programs accept COMLEX alone, especially in primary care specialties. However, some larger academic centers and certain specialties still prefer or require USMLE. Discuss your specific situation with a trusted advisor; avoid adding another low score to your record without a realistic plan to perform better.

3. How many Texas residency programs should I apply to if I want to stay in the Texas Triangle?

If you have low Step or COMLEX scores and want to focus on Houston–Dallas–San Antonio, aim to apply broadly:

• Include all DO-friendly programs within the Triangle in your specialty.
• Add Texas programs outside the Triangle and DO-friendly programs in other states to hedge your risk.
• In total, 40–70 applications is common for DO applicants with lower scores targeting core specialties, with at least 15–30 programs in Texas if possible.

The narrower your geography, the broader your list of specialties and program types should be.

4. Should I address my low scores in my personal statement?

If your low scores are the only major red flag and you have clear evidence of improvement (e.g., better Step 2/Level 2 and strong clinical performance), a brief, focused mention can be helpful. Use 2–3 sentences to:

• Acknowledge the score
• Explain what you learned
• Emphasize the steps you took to improve

Avoid overexplaining or sounding defensive. Let your letters, evaluations, and subsequent achievements carry most of the weight in demonstrating growth.

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By understanding how programs in the Texas Triangle evaluate DO applicants with low scores—and by building a thoughtful, data-driven strategy—you can significantly improve your chances of a successful osteopathic residency match in Houston, Dallas, San Antonio, or elsewhere in Texas. Your scores are one part of your story, not the whole story. Focus relentlessly on everything you can control, and let your work ethic, clinical performance, and commitment to Texas communities define your candidacy.