Essential Strategies for IMGs with Low Step Scores in Surgery Residency

Understanding How Low Step Scores Affect an IMG in General Surgery

For an international medical graduate, general surgery is one of the more competitive specialties—and standardized test scores still matter. A low Step 1 score or below average board scores (Step 2 CK, COMLEX, or equivalent) do not automatically end your dream of becoming a surgeon, but they do fundamentally change your strategy.

Why scores matter in surgery

Program directors in general surgery often receive 800–1,500 applications for a handful of PGY‑1 positions. To manage volume, many programs use numerical filters:

• Step 1: Even after becoming pass/fail for U.S. grads, many programs still look at:
  • Numeric scores of earlier cohorts (including IMGs)
  • Your performance on Step 2 CK as a more current objective measure
• Step 2 CK: Frequently used as the primary numerical filter
• Attempts: Multiple attempts or failures are red flags but not always fatal if the rest of your file is strong and you show improvement

For an IMG in general surgery, low or borderline scores influence:

• Whether your application passes initial filters
• How programs interpret your academic ability
• The number of interviews you receive
• Whether they believe you can handle a demanding surgical curriculum

What “low score” usually means in this context

Definitions vary by program, but for IMG residency guides and typical surgery residency match data:

• Low Step 1: Below ~220 historically, or any failure/attempt
• Low Step 2 CK: Below ~230–235 for competitive surgery programs, or any failure
• “Below average board scores”: Below the mean of matched general surgery applicants in that cycle

You cannot change past scores, but you can:

1. Reduce the impact of those scores
2. Build overwhelming strengths in other parts of your application
3. Target programs intelligently to maximize your chances of matching with low scores

The rest of this IMG residency guide focuses on those three goals.

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Step 1: Honest Assessment and Evidence of Academic Recovery

Before you plan how to overcome a low Step 1 score, you must understand your full academic profile from a program director’s perspective.

Conduct a candid self-assessment

Write down, in one place:

• Step 1 score and number of attempts
• Step 2 CK score and number of attempts
• Any failed clerkships or repeated rotations
• Class rank or decile (if available)
• Medical school reputation and grading system (pass/fail, honors, etc.)

Ask yourself:

• Is Step 2 CK completed?
  If not, this is your immediate priority. For most IMGs with a low Step 1, Step 2 CK becomes your single best chance to “prove the Step 1 score wrong.”

• Is there an upward trend?
  A low Step 1 followed by a strong Step 2 CK (e.g., 240+ range) tells programs you rebounded and learned how to study effectively. This can partly neutralize the earlier concern.

• Are there multiple red flags?
  For example:

  • Low Step 1 + repeated attempts + late graduation
  • Low Step scores + academic gaps
    These scenarios require especially robust compensating strengths (research, U.S. clinical experience, networking, etc.).

Strategic use of Step 2 CK as a recovery tool

If you already have a low Step 1 score, you should treat Step 2 CK as a high‑yield, high‑impact opportunity:

1. Delay application if necessary
   If your Step 2 CK prep is not ready by the start of application season, it is often better to:

   • Take an extra 6–12 months
   • Score significantly higher
   • Apply in a stronger overall position
     than to rush a mediocre Step 2 CK and double‑down on weak numbers.

2. Create a structured remediation plan
   Target why you scored low:

   • Content gaps? → Intensive subject review and Q‑banks
   • Test‑taking skills? → Timed mixed blocks and review of question styles
   • Language/reading speed issues? → Practice with timed reading, summarizing stems aloud
   • Anxiety? → Simulate exam conditions repeatedly, consider professional help if severe

3. Use NBME and UWorld self‑assessments regularly
   Document progressive improvement. This helps with:

   • Personal motivation
   • Framing your story in the personal statement (“I changed my study habits and steadily improved…”)

4. If Step 2 CK is also low
   Focus on trend and context in your narrative:

   • Show improvement over multiple attempts or over time, even if final scores are still below ideal
   • Highlight strengths in surgical rotations, letters, research, and work ethic

When to consider Step 3 early

For IMGs with low Step 1 and Step 2, taking Step 3 before matching can sometimes help:

• Shows you can pass a higher‑level exam
• Some surgery programs (especially community or smaller university programs) see Step 3 as evidence you are less risky to advance

However:

• Do not rush Step 3 if you are not ready; another low score or failure can be more damaging.
• Consider Step 3 early mainly if:
  • You completed Step 2 CK a while ago
  • You are in a reapplication year
  • You have the time and resources to prepare well

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Step 2: Build a “Surgery-First” Profile That Outweighs Low Scores

When matching with low scores, general surgery programs must see a clear, consistent, and credible identity: you are already operating (pun intended) as a future surgeon in training, not just as “an IMG who likes surgery.”

Prioritize high-quality U.S. clinical experience (USCE) in surgery

For IMGs, U.S. clinical exposure in general surgery is often the single most powerful counterbalance to test scores.

Types of USCE that carry weight

In order of value for a surgery residency match:

1. Hands‑on sub‑internships (“sub‑Is”) or acting internships (AIs) in general surgery

   • Typically for senior students or recent graduates
   • You function almost like an intern under supervision
   • Best source of strong, personalized letters from surgeons

2. Hands‑on inpatient surgery clerkships or electives

   • Involvement in:
     • Pre‑rounding, writing notes
     • Presenting on rounds
     • Assisting in OR
   • Demonstrates you can function in a U.S. hospital system

3. Observerships in general surgery

   • Less powerful than hands‑on, but still valuable if:
     • At reputable institutions
     • You are engaged (case discussions, presentations, reading on patients)

4. Research fellowships with clinical exposure

   • Particularly at academic centers with strong surgery departments
   • Can combine research with occasional OR observation and clinic participation

How to turn USCE into match leverage

• Be visibly reliable and tireless

  • Show up early, leave late
  • Take call if allowed
  • Volunteer for tasks no one wants (scut work done with positive attitude is remembered)

• Ask for graded responsibility

  • Present cases on rounds
  • Offer to perform portions of procedures if permitted (suturing, tying, simple skin closures)

• Earn letters of recommendation (LORs) that defend you against your scores Ideal surgery letters for someone with low Step scores should explicitly or implicitly tell program directors:

  • “This applicant may not have the highest scores, but clinically they function at or above the level of our U.S. graduates.”
  • “They are intellectually curious, safe, and capable of mastering complex surgical concepts.”
  • “I would be comfortable having them take care of my own family member.”

Aim for:

• 3–4 LORs
• At least 2 from U.S. general surgeons
• Preferably from surgeons who:
  • Are core faculty or program directors
  • Know you well enough to comment on work ethic, teachability, resilience

Craft a focused, credible narrative of commitment to surgery

Program directors worry that low scores might signal poor discipline or lack of long‑term focus. Your story must show the opposite.

Build a longitudinal “surgery identity”

Include in your CV and ERAS application:

• Surgery‑related electives and clerkships
• Volunteer work in surgical clinics, wound care, trauma centers, or perioperative services
• Teaching roles: anatomy lab TA, surgical skills workshops, peer tutoring for junior students
• Membership and leadership roles:
  • American College of Surgeons (ACS) student/resident sections (if available to you)
  • Surgical interest groups at your school or in your region
• Surgical skills courses or simulation training

Even if your path has detours, the overall pattern should show a persistent pull toward general surgery.

Address low scores in your personal statement the right way

Your personal statement should:

• Acknowledge significant red flags (e.g., failing Step 1) briefly and factually
• Provide short, honest context (without making excuses)
• Emphasize:
  • What you changed (study strategies, time management, wellness)
  • How you improved later (clinical grades, Step 2 CK, clinical performance)
• Spend the majority of the essay describing:
  • Why general surgery specifically
  • What you have done to prepare
  • How you will add value to a residency program

A useful rule:
One concise paragraph about the low score; the rest about your strengths and motivation.

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Step 3: Research, Publications, and Strategic Networking in Surgery

For an international medical graduate with below average board scores, academic involvement and relationship‑building can be decisive.

Why research matters more when your scores are low

In general surgery, especially in university and academic‑affiliated programs, research:

• Signals intellectual curiosity
• Shows you can work hard on long‑term projects
• Helps faculty know you personally, which can bypass electronic filters
• Provides additional talking points during interviews

Even community programs increasingly value some research or scholarly work, especially case reports and quality‑improvement projects.

How to enter surgery research as an IMG

1. Start by identifying realistic targets

   • Universities with:
     • Active general surgery departments
     • A history of recruiting IMGs
     • Published research from departments like trauma, surgical oncology, vascular, colorectal, transplant
   • Use:
     • PubMed (search an institution + “general surgery”)
     • Department websites listing residents and research fellows
     • LinkedIn or alumni networks

2. Send focused, professional emails

   • Concise subject line: “Prospective IMG Research Volunteer – General Surgery”
   • 2–3 paragraph email:
     • Who you are (training, graduation year, visa status)
     • Why their work interests you (reference specific paper or project)
     • What you are asking for (research volunteer, unpaid observer + research, formal research fellowship)
   • Attach a one‑page CV tailored to:
     • Clinical experience
     • Any prior research (even if not surgical)
     • Technical or data skills (Excel, SPSS, R, basic statistics)

3. Be flexible at the beginning

   • Many IMGs start as volunteer researchers or unpaid fellows
   • Earn trust early by:
     • Turning in tasks early
     • Meticulous data handling
     • Willingness to do background literature reviews

Types of research that help a surgery residency match

• Clinical research in general surgery

  • Outcomes analysis
  • Retrospective chart reviews
  • Quality improvement projects (e.g., reducing surgical site infections)

• Case reports and case series

  • Easier to complete
  • Good opportunity for first‑author publications
  • Can be done from observerships if you identify interesting cases

• Conference abstracts and posters

  • Regional or national ACS, trauma, or specialty‑society meetings
  • Presentations build your CV even if full publication is pending

Volume is not everything. Even 2–4 solid, surgery‑focused projects can meaningfully strengthen your profile, especially if they include:

• Co‑authorship with recognized surgeons
• Evidence of your persistence (multiple posters/manuscripts from one fellowship)

Networking: turning contacts into interviews

Networking is often underused by IMGs, but it is critical when you are matching with low scores.

Practical strategies:

• Make yourself known to faculty wherever you rotate or do research

  • Present at journal clubs and M&M meetings if allowed
  • Volunteer to help residents with presentations or research data

• Attend local and national meetings

  • Even attending virtually can help you:
    • Understand the current language and priorities of academic surgery
    • Follow up with presenters by email (“I enjoyed your talk on X; I am an IMG interested in Y…”)

• Ask directly—but respectfully—for support Near application season, talk with mentors:

  • “I plan to apply broadly in general surgery. Do you feel comfortable writing a strong letter?”
  • “Are there programs where you know the program director or faculty who might consider me despite my scores?”

In many cases, a personal email or phone call from a respected surgeon to a program director can encourage a closer look at your file, even if your USMLE scores are below that program’s usual threshold.

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Step 4: Smart Application Strategy and Program Targeting

With low scores, where and how you apply becomes as important as who you are.

Apply extremely broadly—strategically, not randomly

For an IMG with low Step scores aiming for general surgery:

• 40–80+ applications are common
• Some applicants with multiple red flags apply to 100+ programs

However, you should be strategic:

1. Use data to guide your list

   • Look for programs that historically:
     • Have matched IMGs
     • List minimum score thresholds clearly
     • Emphasize holistic review
   • Tools:
     • FREIDA Online
     • Program websites
     • NRMP’s Charting Outcomes (for trends)

2. Classify programs into tiers Roughly:

   • Tier 1 (Reach): University and high‑prestige academic programs.
     • Apply to a few if you have strong research or connections, but don’t rely on them.
   • Tier 2 (Core): Mid‑level university‑affiliated or large community programs that:
     • Have IMGs on current rosters
     • List more flexible minimum scores
   • Tier 3 (Safety): Small community programs, newer programs, programs in less popular locations that:
     • Routinely match IMGs
     • Explicitly consider lower scores or multiple attempts if other aspects are strong

3. Limit categorical‑only applications if very weak

   • If your scores are particularly low, consider applying to:
     • Categorical general surgery
     • Preliminary general surgery spots simultaneously
   • A strong year in a preliminary spot can sometimes lead to:
     • Conversion to categorical in the same program
     • Transfer to a different program with an open PGY‑2 position

Improve your ERAS and program communication

• Optimize your ERAS experiences section

  • Group activities logically (e.g., “General Surgery Research Fellow – Institution X” with clear bullet points)
  • Emphasize surgical tasks, leadership roles, and continuity

• Consider a short, targeted email to selected programs Especially where you have some connection:

  • Rotated or did research at the institution
  • Have a mentor who knows faculty there Include:
  • Brief self‑introduction
  • Your connection to the program
  • One or two unique strengths (e.g., trauma research, extensive OR experience)
  • Expression of genuine interest

Be concise and professional. Avoid asking them to “ignore your score”; instead, give them reasons to look beyond it.

Don’t neglect interview performance

Once you clear the screening phase, interviews are your opportunity to completely reverse the first impression created by your scores.

Prepare for:

• Explaining your low scores calmly, honestly:

  • “At that time I had weaknesses in X; I addressed them by Y; my later performance in Z shows that I learned and improved.”

• Demonstrating surgical mindset:

  • Discuss cases thoughtfully
  • Show you understand long hours, stress, and the physical intensity of surgery

• Highlighting your IMG strengths:

  • Adaptability to new systems
  • Resilience
  • Multilingual skills and cultural competence for diverse patient populations

Mock interviews with mentors, residents, or professional services can help transform your delivery from defensive to confident and self‑aware.

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Step 5: Backup Plans, Reapplication, and Long-Term Mindset

Even with an excellent strategy, general surgery is competitive. You must plan for multiple outcomes without giving up your long‑term surgical goals.

Consider parallel plans without abandoning surgery

Options that keep you close to surgery:

• Preliminary general surgery residency

  • One‑year positions
  • Heavy operative exposure
  • Shows programs you can function in a high‑pressure surgical environment
  • You must perform exceptionally well and network hard to convert to categorical

• Transitional year or preliminary medicine with strong surgical ties

  • Work closely with surgery teams, consult services, or intensive care
  • Build relationships and LORs from surgeons during that year

• Research fellowships (full‑time, 1–2 years)

  • Particularly at institutions that might later consider you for a categorical PGY‑1
  • Use this time to:
    • Publish
    • Present nationally
    • Improve your language/communication, professionalism, and clinical knowledge

When to adjust specialty goals

For some IMGs with strongly low scores or multiple failures, the probability of matching in general surgery may remain low even with significant effort. You may eventually choose to:

• Apply to less competitive surgical fields or surgical adjacencies, such as:

  • Preliminary surgery with long‑term transition to another field
  • Surgical critical care (after other primary residency)
  • Interventional specialties that accept other bases (e.g., interventional radiology after diagnostic radiology, pain procedures after anesthesia)

• Pivot to other specialties where your skills and interests still align, such as:

  • Internal medicine with a later focus on hospitalist or critical care
  • Family medicine with procedures and emergency care

Making this decision should involve:

• Honest discussions with multiple mentors
• Objective review of:
  • Number and quality of interviews
  • Feedback from programs and advisors
  • Financial and emotional costs of repeated unmatched cycles

Protect your mental health and professionalism

Pursuing general surgery as an IMG with low scores is a long, emotionally heavy path. To stay functional and focused:

• Build a support network (family, peers, mentors, therapist if needed)
• Maintain physical health (sleep, exercise, nutrition)
• Have meaningful activities outside medicine to prevent burnout

Residency programs look for resilient people, not just “martyrs.” The strategies you develop to manage disappointment and persevere will serve you in residency and beyond.

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Frequently Asked Questions (FAQ)

1. I failed Step 1 once but passed on the second attempt. Do I still have a chance in general surgery as an IMG?
Yes, but your path is steeper. Many programs have policies about attempts, but some will consider you if:

• Step 2 CK is significantly stronger and passed on the first attempt
• You have strong surgical USCE and excellent LORs
• You show a clear pattern of improvement and insight in your application and interviews

You will likely need to apply very broadly, target programs known to take IMGs, and consider preliminary surgery or research positions.

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2. Is it worth doing a general surgery research fellowship if I already graduated several years ago and have low scores?
Often, yes—especially if:

• The fellowship is at an institution with a surgery residency program that:
  • Has IMGs
  • Occasionally recruits from its research fellows
• You treat the fellowship like a full‑time job, aiming for:
  • Multiple abstracts/posters
  • At least 1–2 publications
  • Strong relationships with faculty

A research fellowship alone does not guarantee a match, but it can significantly strengthen your profile and your credibility when matching with low scores.

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3. Should I take Step 3 before applying to general surgery if my Step 1 and Step 2 CK are low?
Consider early Step 3 if:

• You are in a reapplication cycle
• You have enough time to prepare thoroughly
• You are confident you can pass on the first attempt

A strong Step 3 score can reassure some programs that you can pass future board exams and are less of an academic risk. However, a poor Step 3 performance will worsen your situation, so weigh the decision carefully with input from mentors.

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4. How many programs should I apply to as an IMG with low Step scores seeking general surgery?
There is no exact number, but many applicants in your situation apply to:

• 60–100+ categorical general surgery programs, plus
• A selection of preliminary surgery spots

Your exact number depends on:

• Severity of score deficits and attempts
• Strength of your other credentials (USCE, research, LORs)
• Financial resources

More important than absolute number is smart targeting: programs that actually interview IMGs and are open to candidates with imperfect scores.

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Low USMLE scores or below average board scores do not define your potential as a surgeon—but they do require you to be strategic, persistent, and realistic. By building a robust, surgery‑centered profile, leveraging research and networking, and applying intelligently, many international medical graduates successfully enter general surgery residency—even when the numbers on their score report were not ideal.