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

Applying to internal medicine with a low Step score as a DO graduate can feel daunting—but it is absolutely possible to match with the right strategy. Many successful internists started with below-average board scores and built strong careers through deliberate, focused planning.

This guide lays out a practical, step-by-step approach specifically for DO graduates targeting the internal medicine residency (IM) match with low Step/COMLEX scores.

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Understanding “Low Step Score” as a DO in the IM Match

The term “low score” is relative and depends on your context:

• Low Step 1 score: Below the national mean, or a fail on first attempt
• Below average board scores overall: Step 2 CK / COMLEX Level 2-CE below national averages or below many program cutoffs
• Matching with low scores: Often means overcoming automated filters, program bias, and signal to programs that you can succeed despite test history

As a DO graduate, you face added complexity:

• Some programs have USMLE-only filters, even if they list COMLEX;
• Some university IM programs prefer or require USMLE Step 2 CK;
• Osteopathic applicants may be less familiar to academic IM programs, especially in competitive regions.

Yet internal medicine remains one of the most accessible specialties for applicants with lower scores—particularly for DOs who are strategic, flexible, and proactive.

Key mindset: You are not “fixing” a bad application; you are building a different route to show that you will be a strong, dependable internal medicine resident.

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Step 1: Assess Your Score Profile and Risk Honestly

Before developing a strategy, you need a clear, unemotional view of your current application risk.

1. Map Out Your Full Testing Narrative

Write down:

• COMLEX Level 1, 2-CE, (and 3 if taken): scores and attempts
• USMLE Step 1, Step 2 CK (if taken): scores and attempts
• Any fail, large jump or drop, or significant delay between exams

Patterns programs notice:

• Fail then strong pass: Concerning, but shows resilience and improvement if the later score is solid
• Multiple fails or repeated attempts: Higher risk, but not impossible—will require stronger compensating factors and careful program selection
• Weak early scores with strong Level 2 / Step 2 CK: Often viewed positively, especially in internal medicine
• No USMLE scores as a DO: Not fatal for IM, but limits some academic programs

2. Decide if Taking (or Retaking) an Exam Makes Sense

As a graduate, decisions are more constrained by timing and risk.

Consider a new or additional exam (especially Step 2 CK) if:

• You have only COMLEX and can reasonably score at or above average on USMLE
• You had a low Step 1 score but have reason (NBME practice scores, recent clinical performance) to believe you can do substantially better on Step 2 CK
• You’re targeting more academic internal medicine residency programs that strongly prefer Step scores

Be cautious about retakes:

• Multiple attempts can look worse than a single low score
• If you’ve already failed once, you need clear, objective evidence (NBME practice exams, tutoring progress) that a retake will be substantially better
• Never sit for another exam “to see how it goes”

3. Categorize Your Risk Level

This helps guide how aggressive you can be in the IM match:

• Moderate risk

  • Scores slightly below average, no fails
  • Strong clinical evaluations, no professionalism red flags
  • Some flexibility in program type and geography

• High risk

  • Any exam failure
  • Very low scores (well below common cutoffs)
  • Major gap between preclinical and clinical performance

• Very high risk

  • Multiple failures
  • Very low performance on later exams (COMLEX 2 or Step 2)
  • Non-academic red flags (leave of absence, professionalism concerns)

Each level is still matchable in internal medicine, but the higher your risk, the more important it is to:

• Apply broadly
• Prioritize community-based and DO-friendly IM programs
• Build strong relationships, LORs, and evidence of clinical excellence

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Step 2: Choosing Programs Strategically as a DO Graduate

Your choice of where to apply is as important as how strong your application looks.

1. Target DO-Friendly Internal Medicine Programs

Look for indicators that a program is realistic for a DO with lower scores:

• Programs with a history of matching DOs consistently (check resident rosters)
• Former AOA (osteopathic) internal medicine programs that entered the single accreditation system
• Community-based university-affiliated programs
• Programs at mid-size community hospitals rather than high-prestige academic centers

How to research:

• Resident websites: count how many DOs vs MDs, and how many are IMGs
• FREIDA and program websites: note whether COMLEX is accepted and whether USMLE is required
• Ask upperclassmen, mentors, or attendings where recent DO grads have matched with similar scores

2. Identify and Avoid Hard Score Cutoffs When Possible

Some programs list specific score filters; others do not, but still use them.

Filter out programs that clearly state:

• “USMLE Step 2 minimum 230” (if this is far above your score)
• “No failures accepted” or “First-attempt passes only”

When in doubt, a brief, professional email to the program coordinator can clarify whether:

• They consider applicants with a USMLE failure followed by a strong Step 2 CK
• They accept COMLEX-only applicants
• They rarely or never interview DOs (which might make them a low-yield choice)

3. Balance Program Types by Risk

To improve your chance of an IM match with low scores, your program list might look like:

• 60–80%: Community hospital-based, DO-friendly, lower-to-mid competitiveness
• 10–20%: Community/university-affiliated with more moderate competitiveness
• 0–10%: Aspirational academic university programs (if you have strong non-test strengths like research, MPH, or outstanding LORs)

As a DO with below average board scores, the osteopathic residency match experience has shown that community-focused internal medicine residencies often value:

• Reliability
• Work ethic
• Clinical judgment and bedside manner

—sometimes more than top-tier board performance.

4. Apply Broadly and Early

For DOs with low Step 1 or Step 2 scores trying to match internal medicine:

• Applying to 70–120 programs in IM is common and often appropriate, depending on your risk level
• Always submit ERAS as close to opening day as possible
• If you’re applying in multiple cycles, consider how to adjust your program list based on your prior interview yield

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Step 3: Building a Compelling Application Around Low Scores

You cannot hide your scores, but you can outweigh them with other strengths that matter to IM programs.

1. Use Your Personal Statement to Reframe Your Story

Your personal statement is a critical tool for contextualizing a low Step score without making excuses.

Tips:

• Address major issues briefly, directly, and maturely
  • Example: “During my preclinical years, significant family health issues impacted my performance on COMLEX Level 1. Since then, I’ve developed better time management and coping strategies, which is reflected in my improved clinical evaluations and Level 2 performance.”
• Pivot quickly to strengths:
  • Strong clinical evaluations
  • A specific passion within internal medicine (e.g., hospitalist medicine, primary care, cardiology)
  • Evidence of resilience and growth

Avoid:

• Long explanations blaming circumstances
• Emotional language that sounds defensive or bitter
• Overemphasis on test anxiety without discussing what you did to address it

2. Secure Powerful Internal Medicine Letters of Recommendation

For DO graduates matching with low scores, letters can be make-or-break.

Aim for:

• At least 3 strong IM letters, ideally:
  • 1 from a core IM clerkship director or attending who knows you well
  • 1 from a sub-internship / acting internship (AI) in internal medicine
  • 1 from a hospitalist, subspecialist, or IM faculty at a site where you excelled

Qualities your LORs should highlight:

• Reliability: on-time, prepared, follows through on tasks
• Clinical reasoning: ability to generate thoughtful assessments and plans
• Work ethic: willingness to stay late, follow up on labs and consults
• Teamwork: works well with nurses and ancillary staff
• Professionalism and communication with patients

If possible, do an away rotation or audition rotation at a program or hospital where you might apply—this is a strong way to offset below average board scores with firsthand evidence of your performance.

3. Showcase Clinical Strength in Your Experiences Section

Use the ERAS experience entries to tell a consistent story:

• Highlight longitudinal involvement in internal medicine settings: free clinics, student-run clinics, IM interest groups, QI projects
• Emphasize any leadership roles that show responsibility and reliability
• Include quality improvement (QI) or patient safety projects that appeal to IM PDs
• If you did osteopathic manipulative medicine (OMM/OMT) work:
  • Present it as an asset, especially in primary care or hospital medicine contexts
  • Avoid making it the central focus unless you’re targeting explicitly osteopathic-focused IM programs

4. Use Your MSPE and Transcript to Counterbalance Scores

If your test scores are weak, program directors will look closely at:

• Clerkship grades, particularly in Internal Medicine, Psychiatry, Family Medicine, and Surgery
• Narrative comments in the MSPE (Dean’s letter), such as:
  • “Among the top 10% of students I’ve worked with in the last five years”
  • “Demonstrated exceptional ownership of patient care responsibilities”

If you have honors in IM or a sub-internship, explicitly highlight that in your CV and interviews as evidence that you perform well in real clinical settings even if your exams were below average.

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Step 4: Addressing Low or Failed Scores Proactively

Programs prefer applicants who demonstrate insight and growth. As a DO graduate in the IM match, this matters even more.

1. Prepare a Clear, Honest Explanation

Whether in your personal statement, ERAS “Additional Information,” or interviews, use a simple framework:

1. Fact – Briefly state what happened (low score, failure, delay)
2. Cause – One or two concise contributing factors (study strategy, health issue, personal situation)
3. Action – What you changed (study methods, support systems, scheduling)
4. Outcome – How this shows in your later performance

Example:

“I failed COMLEX Level 1 on my first attempt. At the time, I was using passive learning resources that did not match my learning style, and I underestimated the volume of material. After this, I sought guidance from faculty, began using active-spaced repetition tools, and scheduled structured practice exams. On my second attempt, I passed comfortably, and I have since passed Level 2-CE and demonstrated strong performance in my internal medicine clerkships.”

Key points:

• Take responsibility
• Avoid oversharing personal information
• Emphasize concrete improvements and current readiness

2. Develop a Clear Study Plan for Future In-Training Exams

Program directors worry that low Step scores may predict:

• Difficulty passing the Internal Medicine in-training exam (ITE)
• Risk of failing the ABIM boards after residency

You can partially defuse this by:

• Mentioning in your personal statement or interview that you have a structured approach to board-style studying now (Anki, UWorld, regular self-assessments)
• If you already took an in-training exam (prelim year, preliminary training, or prior PGY-1), be ready to discuss your performance and study approach

Showing that you’re aware of this concern and already have a plan reassures programs that you will not be a chronic academic problem.

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Step 5: Interview and Communication Strategy for the IM Match

Once you secure interviews, your main job is to confirm that your low scores are not reflective of your clinical ability or reliability.

1. Anticipate and Practice Common Questions About Scores

You may be asked directly:

• “Can you tell me about your board scores?”
• “What happened with your Step/COMLEX?”
• “How will you handle the in-training exam?”

Prepare 60–90 second responses that:

• Follow the Fact–Cause–Action–Outcome structure
• Stay calm, confident, and non-defensive
• End on a positive, forward-looking note

Practice out loud with:

• Faculty mentors
• Advisors from your DO school
• Friends doing mock interviews

2. Emphasize Fit, Work Ethic, and Long-Term Commitment to IM

Internal medicine programs—especially community-based ones—value:

• Doctors who can show up, work hard, and be good teammates
• Residents who are committed to continuous learning rather than “score chasing”

Signal this by:

• Sharing concrete examples of times you went above and beyond for patients
• Talking about systems-based practice: QI work, interest in patient safety, or EMR improvements
• Describing your long-term plans (hospitalist vs primary care vs fellowship) in realistic terms

3. Use Thank-You Notes Strategically

After interviews:

• Send personalized thank-you emails within 24–48 hours
• Briefly reiterate:
  • Your interest in internal medicine
  • Why that specific program is a strong fit for your learning style and goals
  • Your appreciation for their consideration given your unique journey

Avoid explicitly mentioning your low scores in thank-you notes; keep them positive and forward-looking.

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Step 6: Considering Backup Plans and Pathways if You Don’t Match

Even with strong preparation, DO graduates with very low scores or major exam failures may not match on the first attempt. This does not end your path to internal medicine.

1. Use the SOAP (Supplemental Offer and Acceptance Program) Wisely

If you enter SOAP:

• Focus on any unfilled internal medicine or prelim IM positions first
• Broaden to prelim surgery, transitional year, or other clinical prelim positions if necessary
• Be realistic and flexible about geography and program type

2. PGY-1 Preliminary or Transitional Year as a Stepping Stone

If you obtain a prelim IM or transitional year:

• Treat it as an extended audition:

  • Excel clinically
  • Build strong LORs
  • Show up early, stay late, and be a reliable team member

• Use your PGY-1 time to:

  • Strengthen your application narrative (now with real postgraduate experience)
  • Consider retaking or taking additional exams only if you have clear evidence that you’ll do better

Many program directors are more willing to overlook earlier low scores if you demonstrate:

• Strong performance in a rigorous PGY-1 year
• Professionalism and teamwork
• Growth in clinical judgment

3. Additional Strengthening Activities Between Cycles

If you don’t match and do not have a clinical PGY-1:

• Seek clinical research coordinator roles in internal medicine departments
• Obtain hands-on clinical experience (e.g., hospitalist scribe, medical assistant under supervision, or structured observerships if allowed)
• Continue academic growth:
  • QI projects
  • Case reports or small publications
  • Continued CME or courses relevant to IM (e.g., ECG interpretation, ultrasound basics)

Avoid long gaps with no clinical relevance; they raise new concerns.

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FAQs: DO Graduates, Low Scores, and the Internal Medicine Match

1. Can I match internal medicine with a low Step 1 score as a DO graduate?

Yes. Internal medicine is one of the more forgiving specialties for a low Step 1 score, especially when:

• Your later exams (COMLEX Level 2 / Step 2 CK) are stronger
• You have solid clerkship performance, especially in IM
• You apply broadly to DO-friendly and community-based programs
• You explain your testing history honestly and show clear growth

Many DO applicants with low Step 1 have successfully matched into solid internal medicine residency programs.

2. Do I need USMLE scores if I already have COMLEX as a DO applying to IM?

Not always, but USMLE can help in certain situations:

• If you’re targeting university-based or academic IM programs, many expect or strongly prefer USMLE Step 2 CK
• If your COMLEX scores are low but you believe you can score significantly higher on USMLE, a strong Step 2 CK can partially offset earlier performance

However, if:

• Your test-taking history is already fragile (failures, very low scores)
• Practice exams suggest you will not be markedly better on USMLE

then adding another risky exam may not be helpful. Weigh this carefully with a trusted advisor.

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

Numbers vary, but general guidance for DO graduates with low scores:

• Moderate risk (no fails, slightly below average): 60–80 IM programs
• High risk (failures or very low scores): 80–120+ IM programs
• Distribute them heavily toward community-based and DO-friendly programs

Your prior interview yield, if you’ve applied before, should also inform how broad you go in subsequent cycles.

4. Will a board failure automatically prevent me from matching internal medicine?

No—many residents in IM have at least one exam failure. But it does:

• Limit some programs that have strict “no failures” policies
• Require you to:
  • Apply more broadly
  • Demonstrate clear upward trajectory (better later scores, strong clinical evals)
  • Present a mature, accountable explanation in your application and interviews

Your goal is to convince programs that the failure was an event, not a pattern—and that the IM residency will be getting a diligent, teachable, and dependable resident.

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A low Step score or below average board scores as a DO graduate do not close the door to internal medicine. They simply require a more deliberate, tailored strategy. By choosing programs wisely, highlighting your clinical strengths, addressing your testing history with maturity, and demonstrating genuine commitment to IM, you can build a compelling application and successfully navigate the internal medicine residency match—even with low scores.