Essential Strategies for IMGs with Low Step Scores in Preliminary Surgery

Understanding the Landscape: Low Scores, IMGs, and Preliminary Surgery

International medical graduates aiming for surgery face a double challenge: being an IMG and having a low Step score (or below average board scores overall). When you add the unique nature of a preliminary surgery year—often used as a bridge to categorical surgery or another specialty—the strategy must be very deliberate.

This IMG residency guide focuses specifically on low Step score strategies for those targeting a prelim surgery residency. We will not pretend scores don’t matter; they do. But for many programs, particularly for prelim positions, they are only one part of the decision.

First, some definitions and context:

• Low Step score / below average board scores
  This varies by year and by program. In general, for IMG applicants to surgery:

  • USMLE Step 1: Below ~225–230 may be considered relatively low for competitive surgical programs; significantly below that (<215) is a notable red flag, especially if failed.
  • USMLE Step 2 CK: Below ~235–240 can be considered below-average for surgical applicants; <225 is typically concerning.

• Preliminary surgery year vs. categorical surgery

  • Categorical surgery: A full 5+ year general surgery position leading to board eligibility.
  • Preliminary surgery: A 1-year position without guaranteed continuation. Used for:
    • Candidates hoping to transfer into categorical surgery later.
    • Applicants heading into other fields (e.g., radiology, anesthesia, urology) that require a clinical year.
    • Applicants who need strong US clinical experience (USCE) and letters to strengthen a re-application.

• Why prelim surgery can be strategic for an IMG with low scores

  • More open positions relative to categorical spots.
  • Some programs are more flexible with scores for prelims, prioritizing work ethic and reliability.
  • It can provide:
    • Robust US clinical experience
    • Powerful letters of recommendation
    • A chance to prove you outperform your test scores in a demanding clinical environment.

The goal of this article is to show you how to turn a weak board portfolio into a stronger overall application for a prelim surgery residency—and how to use that year wisely, if you obtain it.

---

Step Scores in Context: How Program Directors View Low Scores

Before you can develop a good strategy, you need to understand how PDs think about board scores, especially for IMGs aiming at prelim surgery.

What low scores signal to program directors

Program directors may worry that low or failing scores suggest:

• Difficulty handling knowledge-heavy subjects (anatomy, physiology, pathophysiology).
• Possible test-taking weakness, which matters because of ABSITE and board exams.
• Inconsistency or lack of discipline.
• Risk of poor in-training exam (ABSITE) performance that might hurt program metrics.

Even for prelim positions, these concerns are real. But there’s nuance:

• Many PDs believe performance in residency ≠ performance on USMLE.
• A strong Step 2 CK, great LORs, and strong clinical evaluations can convince them you are reliable and capable, despite low scores.
• Some surgery departments have historically used score cutoffs only for categorical positions, being more flexible for prelims.

Step 1 pass/fail era: What changes for IMGs?

If your Step 1 is now listed as Pass/Fail, “low Step 1 score” becomes less relevant, but you may still be affected if:

• You took Step 1 before the change and have a clearly low numerical score.
• You failed Step 1 or Step 2 on a previous attempt.
• Your Step 2 CK is significantly weaker than peers (your main numerical board metric now).

Surgeons increasingly emphasize Step 2 CK and clinical performance. That is actually an advantage if your clinical strengths outshine your test performance.

Key takeaway: You cannot erase low scores, but you can reframe them and outweigh them with other strengths that matter greatly to surgical PDs, especially for a prelim surgery year.

---

Core Application Pillars: How to Counterbalance Low Scores

When you are matching with low scores, every other dimension of your prelim surgery application must be intentional and optimized. Think of your application as a 6-pillar structure:

1. USMLE narrative and score trajectory
2. US clinical experience (USCE) with surgical exposure
3. Letters of recommendation (LORs) from surgeons
4. CV & personal statement tailored to prelim surgery
5. Program-targeted application strategy
6. Interview performance & communication

1. USMLE Strategy: Mitigation and Narrative

Even though you can’t change past scores, you can still optimize this pillar.

a. If you have not taken Step 2 CK yet

• Aim for a strong Step 2 CK to offset a low Step 1.
  • Put extra time into high-yield resources and NBME self-assessments.
  • If you failed or scored very low before, consider test-taking coaching or a formal course.
• Delay application if needed to avoid another weak score:
  • A late but stronger Step 2 CK is better than a rushed, poor score.

Programs will often forgive a low Step 1 if:

• Step 2 CK is significantly higher, and
• You present a clean, upward trend.

b. If your Step 2 CK is already low

Your priority becomes damage control and reframing:

• Highlight improvement within the test report, if present (e.g., stronger performance in surgery-related systems).
• If you had a clear life circumstance (family emergency, illness), you may briefly explain it in:
  • Personal statement, or
  • ERAS “Additional Information” section
    Do this once, briefly, and then pivot quickly to how you’ve improved.

c. If you failed any Step

• PDs will look closely at:
  • Subsequent passes and score improvement
  • Length of delay between attempts
• Your strategies:
  • Demonstrate that the failure led to concrete changes: better study methods, formal prep, mentorship.
  • Emphasize that you now consistently pass high-stakes assessments (e.g., Step 3 if taken, ABSITE-like practice results, in-training evaluations during rotations).

Actionable tip:
Prepare a 2–3 sentence, calm, factual explanation about your low or failing score for applications and interviews. Practice it aloud until it’s fluent and unemotional.

---

2. US Clinical Experience: Surgery-Focused and High-Impact

For IMGs, USCE can outweigh low scores, especially if:

• It is recent (within the last 1–2 years).
• It is surgery-focused.
• It results in specific, strong LORs.

Types of USCE that help most for prelim surgery

From most to least valuable for a prelim surgery context:

1. Inpatient general surgery sub-internships (“sub-Is”)

   • Highest impact if you function as part of the team (writing notes, presenting patients).
   • Try to secure these at programs that actually offer prelim positions.

2. Acting internships / audition electives

   • Particularly if you’re allowed to take call, scrub in frequently, and be evaluated alongside U.S. seniors.

3. Surgical observerships with meaningful involvement

   • Observerships are less powerful than hands-on electives, but:
     • Multiple months, at recognizable hospitals, with close attending contact can still yield strong letters.

4. Non-surgical USCE (medicine, ICU, ED)

   • Still useful to show:
     • Communication skills, professionalism, and team function.
   • Can provide backup LORs if surgical letters are limited.

How to convert USCE into competitive advantage

During any surgical rotation, focus on behaviors that PDs love:

• Reliability: Arrive early, never miss sign-out, know your patients in detail.
• Work ethic: Stay late if needed, volunteer for tasks, avoid complaining.
• Initiative:
  • Read about cases you are scrubbing into.
  • Offer to present on a topic at a resident conference.
• Teachability: Accept feedback, improve quickly, show you’re coachable.

Ask for formal written evaluations and, when possible, mid-rotation feedback so you can adjust and end strong.

---

3. Letters of Recommendation: Your Most Powerful Counterweight

For an IMG with low Step scores, letters of recommendation (LORs) can often matter more than the numbers for prelim surgery positions.

Which letters matter most?

Prioritize:

1. US general surgery attendings who:

   • Supervised you directly.
   • Saw your work ethic repeatedly.
   • Are willing to comment in detail, not just generically.

2. Surgical subspecialty attendings (vascular, trauma, colorectal, etc.) who:

   • Can speak to your operative presence, teamwork, or on-call reliability.

3. Internal medicine or ICU attendings only if:

   • You lack enough surgical letters, or
   • They can document exceptional clinical performance.

Try to secure at least two strong letters from US surgeons.

How to get strong, specific letters

Well before your rotation ends:

1. Ask for feedback: “Is there anything I can do to be a stronger candidate for a preliminary surgery position?”
2. Signal your goals: “I’m an IMG aiming for a prelim surgery residency. If you feel you can support me, a strong letter from you would be extremely helpful.”
3. Provide:
   • Updated CV
   • Personal statement draft (even if rough)
   • A brief bullet list of cases and responsibilities you had with them

This helps the writer:

• Remember your specific contributions.
• Mention concrete examples (“stayed until 11 PM to help with a septic patient,” “read about each case before the OR”).

Red-flag to avoid:
Vague or generic letters are almost as bad as no letter, especially if from “big names” who didn’t work closely with you. Programs care more about content than prestige.

---

Crafting a Compelling Story: CV, Personal Statement, and Program Strategy

When matching with low scores, your narrative must be coherent: everything in your application should point toward preliminary surgery as a deliberate, logical step, not a desperate last resort.

1. Personal statement: Turn weaknesses into a structured plan

Your personal statement for a prelim surgery residency should:

• Clearly state why surgery:
  • Specific patient encounters, OR experiences, or procedural enthusiasm.
• Acknowledge (briefly) your testing history only if necessary:
  • Example: “While my Step scores do not fully reflect my clinical strengths, they motivated me to redesign my study strategies and pursue more hands-on surgical experiences, which have been consistently strong.”
• Emphasize:
  • Work ethic
  • Resilience
  • Growth and adaptability
  • Teamwork and communication

For a prelim year focus on:

• What you can offer:
  • Reliable coverage, high-volume work, willingness to help seniors, night float, etc.
• What you seek from the prelim year:
  • Robust surgical experience
  • Mentorship
  • Opportunity to build a stronger record for future training (surgery or another field)

Avoid sounding like you treat the prelim as a stepping stone only; programs want prelims who will:

• Work hard.
• Integrate into the team.
• Maintain morale.

You can be honest about long-term goals (e.g., categorical surgery) while emphasizing full commitment to the prelim role.

2. CV and experiences: Highlight surgical commitment

Even if your academic metrics are modest, your CV can show:

• Long-standing interest in surgery:
  • Surgical electives
  • Surgical interest group involvement
  • Volunteer work in OR-adjacent spaces (e.g., perioperative clinics, trauma centers)
• Research or quality improvement:
  • Even small projects (chart reviews, case reports) in:
    • Trauma, general surgery, vascular, etc.
• Teaching and leadership:
  • Tutoring junior students
  • Leading skills workshops
  • Organizing morbidity and mortality (M&M) preparatory sessions

For each experience, frame responsibilities and outcomes:

• “Assisted in clinic flow and pre-op evaluation for 20+ patients weekly.”
• “Participated in weekly trauma conference and presented 3 cases.”

3. Program strategy: Where and how you apply matters

For an international medical graduate with low Step scores, program targeting is critical.

a. Prioritize programs that are realistic for prelim surgery

Programs more likely to consider you:

• Have multiple prelim positions each year.
• Have a history of hiring IMGs.
• Are in less competitive geographic areas (Midwest, South, smaller cities, community programs).
• List no fixed score cutoff or more flexible minimums on their websites or FREIDA entries.

Avoid spending most of your effort on:

• Ultra-competitive academic programs in major metropolitan centers with strong categorical match outcomes and very high average board scores.
• Programs explicitly stating they do not sponsor visas if you need one.

b. Apply broadly and strategically

• For a prelim surgery target with low scores, consider:
  • 40–80+ applications to prelim surgery programs, depending on your budget and strength in other domains.
• Consider backup specialties that are more forgiving of low scores:
  • Internal medicine prelim or transitional year
  • Categorical internal medicine in community programs (if your long-term goal may adjust).

In ERAS, clearly label that you are applying to:

• Preliminary surgery positions
• Possibly a small number of categorical surgery programs (if you have other strong factors) but do not rely on these.

---

Interview and Communication Strategy: Owning Your Story

If your application secures interviews, the biggest determinant of success will be how you communicate your narrative and address your scores confidently.

How to discuss low Step scores in interviews

Your goals:

• Be honest but not defensive.
• Show growth, insight, and maturity.
• Briefly explain, then redirect to strengths.

Example answer framework:

1. Acknowledge:
   • “My Step scores are not as strong as many surgical applicants.”
2. Provide a simple explanation (if there is one):
   • “At the time, I was balancing a heavy clinical schedule and did not approach preparation as systematically as I should have.”
3. Demonstrate learning:
   • “Since then, I changed my approach—built a daily schedule, did timed questions, and sought mentorship. This led to improved performance on clinical rotations and in my institutional exams.”
4. Pivot:
   • “More importantly, my clinical supervisors consistently rated me highly for work ethic and reliability, and I believe my performance on the wards and in the OR better reflects the resident I will be.”

Avoid:

• Blaming others (school, exam format, unfair circumstances) excessively.
• Over-sharing personal issues beyond what is necessary.

Highlighting strengths that matter most to surgical PDs

Many PDs repeat similar themes about the ideal prelim resident:

• “I want someone who is reliable, who shows up and works hard every day.”
• “A good prelim resident is teachable and helps the team run smoothly.”
• “Scores are less important than professionalism and behavior on the floor.”

Use examples to illustrate these traits:

• Times you stayed late without being asked.
• Times you took responsibility for a mistake and corrected it.
• How you interacted with nurses, residents, and patients.

Asking smart questions in interviews

Demonstrate your seriousness about a prelim surgery year by asking about:

• How their prelim residents are integrated with categorical residents.
• What proportion of prelims go on to:
  • Categorical positions (inside or outside the institution)
  • Other specialties
• Opportunities for:
  • Surgical research
  • ABSITE-like teaching
  • Mentorship meetings with faculty

This shows you understand the prelim year as part of a larger training pathway, not just a way to get a visa or US experience.

---

Using the Prelim Year Wisely if You Match

If you do secure a prelim surgery residency, it can dramatically change your long-term prospects—even with low initial scores—if you approach it correctly.

Goals during your prelim surgery year

1. Be the resident everyone wants on their team

   • Arrive early, leave late when needed.
   • Anticipate tasks, not just respond to them.
   • Maintain a positive, respectful attitude under stress.

2. Build new, powerful letters

   • From program leadership (PD, chair) and senior faculty.
   • From chiefs who can speak to your reliability and operative growth.

3. Ace your ABSITE (if allowed to take it)

   • Low USMLE scores + strong ABSITE = powerful evidence you overcame earlier weaknesses.
   • Schedule study throughout the year (1–2 hours most days, plus question banks).

4. Network actively and honestly

   • Let faculty know your goals (categorical surgery vs. another specialty).
   • Ask what you can do to be a stronger candidate.

5. Protect your wellness and professionalism

   • Burnout can lead to errors and interpersonal conflicts, which are more damaging than any exam score.
   • Seek help early if overwhelmed; programs prefer that to silent suffering.

Planning your re-application strategy

By mid-year, you should:

• Meet with your PD or advisor:
  • Ask candidly: “Based on my performance so far, where do you see me matching next cycle?”
• Prepare:
  • Updated CV with prelim year accomplishments.
  • New personal statement emphasizing:
    • Your growth during residency.
    • Strong evaluations and support from current faculty.

Some prelim residents secure:

• Categorical surgery positions at their own institution or elsewhere, or
• Entry into another specialty (e.g., anesthesia, radiology, internal medicine) that values their surgical year.

---

Frequently Asked Questions (FAQ)

1. Can I realistically get a prelim surgery spot as an IMG with low Step scores?

Yes, it is realistic—but not guaranteed. Many programs use prelim positions to fill service needs and are more flexible with scores compared to categorical slots, especially if you:

• Have recent US surgical experience.
• Obtain strong US surgical LORs.
• Show professionalism and commitment in your application.

Expect to apply broadly, focus on realistic programs (especially community and less competitive regions), and be prepared with a compelling narrative.

---

2. Should I take Step 3 before applying to offset low Step scores?

It depends:

• Helpful if:

  • You have prior failures or very low scores and can demonstrate clear improvement with a strong Step 3.
  • You need Step 3 for certain visa or state licensure requirements.

• Risky if:

  • You are not fully prepared and might produce another low or failing score.

If you choose to take Step 3, treat it as a high-stakes opportunity to prove change, not just another exam.

---

3. Is it better to apply to a prelim surgery year or directly to internal medicine if my scores are low?

It depends on your true long-term goals:

• If you are committed to surgery and are willing to accept the uncertainty of a 1-year position, a prelim surgery year can be a powerful stepping stone.
• If your primary goal is a stable categorical residency in the US, and you are flexible about specialty, then:
  • Categorical internal medicine or another field with more predictable IMG pathways may be better.

You can also apply to both (prelim surgery + IM) in the same season, but your personal statement and interviews must remain coherent and honest.

---

4. How many programs should I apply to as an IMG with low scores targeting prelim surgery?

There is no universal number, but in practice:

• Many IMGs with low or below average board scores apply to 40–80+ prelim surgery programs, depending on:
  • Budget
  • Visa needs
  • Available programs in regions they can relocate to

The key is to:

• Include a large proportion of programs that historically:
  • Take IMGs
  • Have multiple prelim spots
  • Are in less competitive geographic regions

Pair this with surgical USCE and strong LORs, and you maximize your chances even with numerical disadvantages.

---

By understanding how program directors view low scores, optimizing every other aspect of your application, and—if you match—using the preliminary surgery year strategically, you can transform a weak test history into a credible pathway toward a surgical or surgery-adjacent career in the United States.