Low Step Score Strategies for DO Graduates in Emergency Medicine Residency

Understanding How Low Scores Affect an EM Application

When you are a DO graduate aiming for an emergency medicine residency with a low Step 1 / Level 1 or Step 2 CK / Level 2 CE score, the first step is to understand what “low” means and how EM program directors interpret these numbers.

What counts as a “low” score?

Exact numbers change year to year, but in broad terms:

• USMLE Step 1 (now Pass/Fail) / COMLEX Level 1

  • Concern is now less about numerical cutoffs and more about:
    • First-time pass vs. failure
    • Overall testing history (multiple attempts across exams)

• USMLE Step 2 CK / COMLEX Level 2 CE

  • “Below average” or “low Step 1 score”–type concerns usually mean:
    • Scoring below the national mean
    • Being near or below common program cutoffs
    • Having one or more exam failures

For DO graduates who only took COMLEX:

• Some EM programs prefer or require USMLE; others are COMLEX-friendly.
• A relatively low Level 1/2 score or a fail is what typically raises concern.

From a program’s perspective, low or below average board scores signal potential risk with:

• In-service exams
• Board certification
• Handling the cognitive load of EM training

Your goal is to decrease perceived risk by showing:

1. You can handle the academic rigor.
2. You bring other high-value strengths that matter in emergency medicine.

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Step 1: Clarify Your Exam Profile and Risk Factors

Before building a strategy, define your specific situation.

Categorize your testing profile

Ask yourself:

1. Pass/Fail History
   • Any failed attempts on:
     • Step 1 / COMLEX 1
     • Step 2 CK / COMLEX 2 CE
     • Step 3 / COMLEX 3 (if taken)
2. Score Strength
   • Are your scores:
     • Just a bit below average?
     • Substantially below common EM cutoffs?
3. Trend Over Time
   • Did you improve from Step 1/Level 1 → Step 2/Level 2?
   • Or was there decline or inconsistent performance?

Then place yourself into one of these categories:

• Category A: Single Low Score, Otherwise Solid
  • Example: Step 1 low, but Step 2 CK or Level 2 CE at or above national mean, no failures.
• Category B: Multiple Low Scores, No Failures
  • Both pre-clinical and clinical exams below average, but all first-time passes.
• Category C: One Failed Attempt, Improved Later
  • Failed one exam, then passed later attempts with clear improvement.
• Category D: Multiple Failures or Very Low Scores
  • Repeated failures or very low scores across multiple exams.

Each category requires slightly different strategy intensity. Category A applicants may still be competitive for many emergency medicine residency programs; Category C and D need a more aggressive, targeted plan.

Identify your EM-specific strengths

Because you are a DO graduate targeting emergency medicine, you already have potential differentiators:

• Exposure to osteopathic manipulative treatment (OMT) – even if not a central EM skill, it demonstrates hands-on comfort and a holistic care approach.
• Possibly strong clinical evaluations, especially in rotations with fast pace or procedure-heavy services.
• Often robust training in communication and whole-person care, which is highly valued in EM.

Map out your assets:

• EM rotation grades & comments
• SLOEs (Standardized Letters of Evaluation) or potential EM letter writers
• Leadership, community service, EMS/prehospital experience, or research
• Any unique background relevant to emergency medicine (e.g., prior EMT/paramedic, military, athletic trainer, scribe, nurse)

You will later use these strengths to offset the concern raised by your scores.

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Step 2: Know How EM Programs View DO Applicants with Low Scores

Understanding the EM match landscape for DOs helps you target programs intelligently and avoid unnecessary rejections.

Allopathic vs osteopathic emergency medicine programs

There is no longer a separate “osteopathic residency match,” but legacy patterns remain:

• Former AOA (osteopathic) EM programs

  • Often more familiar with COMLEX-only applicants.
  • More likely to look holistically at DO graduates, especially those with strong clinical performance and letters.
  • May have more flexibility when they see matching with low scores but strong DO training.

• Historically ACGME (allopathic) EM programs

  • Frequently prefer or require USMLE scores.
  • Some will still interview COMLEX-only applicants, but:
    • Many publish Step 2 CK/COMLEX 2 CE cutoffs.
    • Several quickly filter out below-score-threshold applications.

As a DO graduate in EM with a low Step 1 score or below average board scores:

• Consider taking or having taken USMLE Step 2 CK if you haven’t already, particularly if you’re targeting formerly ACGME-heavy regions or competitive urban programs.
• If you have only COMLEX and low scores, focus your list more on programs historically DO-friendly and former AOA programs.

What matters to EM PDs beyond scores

EM is a team-based, high-intensity specialty; program directors value:

• Strong SLOEs (or EM-focused letters if SLOEs are not available)
• EM rotation performance (shift comments, clinical initiative, reliability)
• Professionalism and “someone I’d want on my team at 3 am”
• Ability to handle stress and uncertainty
• Procedural skills and willingness to learn
• Evidence of genuine interest and commitment to EM

A DO graduate with lower exam performance but stellar EM rotation reviews and SLOEs can absolutely be chosen over a higher-scoring applicant who appears disengaged or unreliable.

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Step 3: Strengthening Your Application to Offset Low Scores

Your strategy is to build such a strong profile in other areas that programs are willing to accept the risk of your exam record.

1. Prioritize outstanding EM clinical performance

For emergency medicine residency, your rotations are your audition.

Do multiple EM rotations if possible:

• At least one away rotation at a program where you’d be happy to match.
• Consider two EM rotations if your application is otherwise weaker or you lack strong home institution EM exposure.

On your rotations:

• Show up early, leave late, volunteer for procedures.
• Ask for feedback mid-rotation: “I’m really interested in EM. Is there anything I can do to improve my performance this month?”
• Demonstrate rapid follow-up: if they suggest reading about chest pain pathways, come back next shift ready to discuss.

These behaviors translate into:

• Strong written comments
• Higher likelihood of top-tier SLOEs
• Letter writers willing to explicitly reassure PDs about your work ethic and clinical ability despite low scores

2. Secure powerful letters of recommendation (especially SLOEs)

For EM, SLOEs are often more important than test scores.

Aim for:

• 1–2 SLOEs from EM faculty/core faculty or PDs where you rotated.
• If SLOEs are not available, EM-focused letters that mimic SLOE structure (comparative, concrete, specific).

Ask letter writers explicitly:

• “Given my board score history, do you feel you can write a strong letter that will help mitigate those concerns?”
• This is not rude; it’s savvy. If they hesitate, choose another writer.

In your best SLOEs, you want descriptors like:

• “One of the top EM rotators we’ve had this year”
• “Performance places them in the top 1/3 (or 1/4) of students”
• “We would strongly recommend for our own residency program”

A DO graduate with a low Step 1 score but comments like these will stand out in the EM match.

3. Create a compelling narrative in your personal statement

Your personal statement is not the place to write a page-long apology for low scores, but it can be used strategically.

Use it to:

• Emphasize why EM and why you’re a great fit (teamwork, communication, resilience).
• Highlight examples of:
  • Handling chaos calmly
  • Multitasking
  • Owning patient care
• Briefly and maturely address exam issues if:
  • There is a clear and honest explanation (illness, family crisis, late diagnosis of learning disability) AND
  • You can show improvement and concrete changes you made.

Guidelines for addressing low scores:

• 1–3 sentences, concise.
• Take responsibility without self-pity.
• Emphasize growth: “I have since adopted X, Y, Z strategies, which led to improved performance on later exams and in my clinical work.”

For example (adapted, not to copy verbatim):

During my pre-clinical years, I struggled with test-taking and time management, which contributed to a lower-than-expected score on my Level 1 examination. Since then, I worked closely with our learning specialist, adopted evidence-based study strategies, and focused on spaced repetition and question-based learning. These changes are reflected in my subsequent testing and, more importantly, in my consistent clinical performance on EM and other core rotations.

4. Show academic improvement and readiness

If you have a low Step 1 / Level 1 score but haven’t taken Step 2 CK / Level 2 CE yet, your number one academic priority is to crush your clinical exam.

• Delay applications if necessary to:
  • Take Step 2/Level 2 early enough for programs to see an improved score.
• If you scored below average previously, aim for:
  • At least solidly around or above the mean on Step 2 CK / Level 2 CE.
• Demonstrate a positive trend: even a modest but clear improvement shows growth and reduces risk.

If your tests are already done and remain low:

• Strengthen your case with:
  • Strong in-training exam scores if you do a transitional year or prelim year.
  • Additional courses (e.g., online EM or critical care coursework with graded assessments).
  • Evidence of dedicated self-study and EM knowledge (e.g., EM bound reading, FOAMed engagement, conference attendance), referenced in letters if possible.

5. Consider a strategically chosen gap year (only for some applicants)

For DO graduates in Categories C–D (failures, very low scores), a structured “bridge” year can help:

Options:

• Transitional year (TY) or preliminary medicine/surgery year
  • If you can obtain one, do so in a program that includes significant ED time.
  • Excel clinically and academically; obtain new letters attesting to your growth.
• Research year in EM
  • Join a department with active EM research.
  • Gain mentorship, publications/posters, and new EM-focused letters.
• Clinical work (e.g., scribe, urgent care provider if licensed, etc.) isn’t as powerful as formal GME, but can still support your narrative of dedication to EM.

Important: A gap year is helpful only if it materially changes your profile and provides new evidence countering the concerns raised by your low or failing exam history.

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Step 4: Smart Program Targeting for the EM Match

Even a very strong strategy can fail if you apply to the wrong mix of programs. For a DO graduate with low scores, list construction is critical.

Build a realistic program list

When planning your emergency medicine residency applications:

1. Research program culture toward DOs

   • Look at:
     • Current residents’ medical schools (DO representation?)
     • Program website statements about COMLEX vs USMLE.
   • Seek former AOA or historically DO-inclusive programs.

2. Check score cutoffs (if available)

   • Some programs publicly state minimum Step 2 CK or COMLEX 2 CE scores.
   • If you are significantly below, consider those programs very unlikely unless you have a powerful personal connection or unique angle.

3. Balance your list

   • For applicants with low scores:
     • Apply broadly: 35–60+ EM programs is not unreasonable if you can afford it.
     • Include:
       • A minority of “reach” programs (better fit if other aspects are strong).
       • A large core of realistic programs (where DOs are common and cutoffs are closer to your scores).
       • Some “safety” considerations, such as:
         • EM programs in less popular geographic areas.
         • Community-based programs rather than heavily academic ones.

4. Think about geography strategically

   • Less competitive regions often:
     • Have fewer applicants.
     • Are more open to applicants with low Step 1 scores or below average board scores.
   • Being flexible on location markedly increases your odds of matching in emergency medicine.

Use signals & communications wisely (if applicable)

If the current application cycle uses preference signaling (e.g., ERAS signaling, program signals):

• Use your highest signals on programs where:
  • You are a reasonable fit.
  • You have done away rotations.
  • You have a realistic chance of interview (not ultra-reach programs where your scores are far below their usual range).

Polite, concise post-interview or pre-interview communications can help if:

• You have a strong regional tie.
• You can offer a clear reason the program fits your goals.
• You avoid pleading about scores—focus on fit, commitment, and what you bring to the team.

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Step 5: Executing on Interview Day and Rank Strategy

Once you secure interviews, your low scores recede in importance; now programs judge whether you are someone they want to work with for three or four years.

How to address scores if they come up on interviews

If asked directly about your low Step 1 score, low Level 1, or exam failures:

• Be honest, concise, and accountable.
• Use a simple structure:
  1. Acknowledge the issue.
  2. Brief explanation (if relevant).
  3. Emphasize what you changed and how you improved.
  4. Pivot to demonstration of current competence.

Example framework:

I recognize that my Level 1 score doesn’t reflect the physician I am now. At that time, I struggled with test anxiety and inefficient study methods. I worked with our learning support team, shifted to a question-based approach, and built a consistent schedule. Those changes helped me perform more solidly on Level 2 and, more importantly, have translated into strong performance on my EM rotations. My attendings have repeatedly commented on my preparation and clinical reasoning, and I’m confident in my ability to handle the academic demands of your program.

Avoid:

• Long, emotional stories that derail the conversation.
• Blaming others without owning your part.

Demonstrate EM-specific strengths during interviews

Program directors know boards are not the whole picture. During interviews, show:

• Team-oriented mindset: talk about collaborative experiences in the ED, ICU, or other rotations.
• Resilience: examples of difficult shifts or situations where you adapted and learned.
• Communication skills: how you handle upset families, consultants, and interprofessional teams.
• Interest in EM as a career, not just as a backup.

As a DO, you can also:

• Highlight how your osteopathic training taught you to assess the whole person—useful in EM when social determinants and psychosocial context often drive ED visits.

Rank list strategy

When creating your rank list:

• Rank programs based on true preference, not perceived chances.
• Do not try to game the algorithm by ranking lower-tier programs higher “just to be safe.”
• However, make sure your interview list includes:
  • A mixture of places where you’d be happy and where you’re realistically competitive.

If you end interview season with:

• Very few EM interviews (e.g., <8), consider:
  • Applying to categorical prelim or TY programs during SOAP as a bridge if unmatched.
  • Having a parallel plan (e.g., FM or IM) only if you are genuinely interested; never list a specialty you would be miserable in.

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Special Considerations for DO Graduates with Very Low Scores

For applicants in Category C or D—multiple failures or significantly low exams—matching into EM directly may be possible but often requires a multi-cycle or creative plan.

Path 1: Strengthen and reapply EM

If you went unmatched in EM or have a severely concerning exam history:

• Obtain a Transitional Year (TY) or prelim medicine/surgery spot.
• During that year:
  • Excel on rotations, especially ED and ICU.
  • Obtain glowing letters from attending physicians.
  • If you have not passed all licensing exams, focus on passing and showing improvement.
• Reapply to EM with:
  • Clear evidence of growth.
  • Strong endorsements from residency faculty.

Path 2: Switch target specialty thoughtfully

Sometimes, despite best efforts, direct EM entry is very difficult. Consider:

• Family Medicine with a plan to emphasize urgent care/acute care components.
• Internal Medicine with an eye toward critical care or hospital medicine.

This is highly individualized. Before abandoning EM:

• Speak with:
  • EM advisors
  • Your Dean’s office
  • Trusted EM mentors
• Clarify whether your profile is truly non-viable for EM, or simply requires a longer pathway.

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Practical Action Plan Checklist

To tie it all together, here’s a concrete roadmap for a DO graduate in EM with low or below average board scores:

1. Clarify Your Profile

   • List all exam scores and attempts.
   • Categorize yourself (A–D).
   • Identify trends and any improvements.

2. Plan Your Exams

   • If Step 2 CK / Level 2 CE is upcoming:
     • Create an aggressive, structured study plan.
     • Consider a dedicated period free from rotations if possible.
   • Aim to show upward trajectory.

3. Maximize EM Rotations

   • Schedule at least one away EM rotation.
   • Treat each shift as an extended interview.
   • Seek mid-rotation feedback and implement it.

4. Secure Strong Letters

   • Identify potential EM letter writers early.
   • Ask explicitly if they can strongly support you given your exam history.
   • Aim for 1–2 SLOEs if available.

5. Craft Your Application Narrative

   • Write a concise, focused personal statement emphasizing:
     • Fit for EM
     • Teamwork
     • Resilience
   • Address exam issues only briefly and constructively.

6. Apply Broadly and Strategically

   • Build a list of 35–60+ EM programs if scores are significantly low.
   • Focus on DO-friendly and former AOA programs.
   • Use preference signals wisely if available.

7. Prepare for Interviews

   • Practice a specific, honest answer to “Tell me about your board scores.”
   • Prepare stories that highlight EM-relevant skills.
   • Demonstrate insight and maturity.

8. Have a Backup Plan

   • Understand SOAP and alternative PGY-1 options (TY, prelim).
   • Decide in advance if you would consider another specialty.
   • Keep mentors looped in throughout the process.

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FAQs: DO Graduate Emergency Medicine Match with Low Scores

1. Can I match into emergency medicine with a low Step 1 score or low COMLEX Level 1 as a DO?

Yes. Many DO graduates with low Step 1 or Level 1 scores match into emergency medicine residency each year. Success hinges on:

• Demonstrating improvement on Step 2 CK / Level 2 CE, if possible.
• Obtaining strong EM rotation evaluations and SLOEs.
• Applying broadly to DO-friendly and former AOA programs.
• Building a coherent narrative that shows you are reliable, hard-working, and passionate about EM.

While very low or failing scores make things harder, they do not automatically end your chances.

2. Do I need to take USMLE Step 2 CK if I already have COMLEX scores?

Not always, but it can help:

• If you’re a DO with only COMLEX and below average board scores, some EM programs may not fully understand how to interpret your scores.
• Taking Step 2 CK:
  • Gives programs a directly comparable metric.
  • Can demonstrate improvement if you perform better than on Level 1/2.
• However, if your previous performance suggests you might do even worse, you must discuss risks with mentors and advisors before deciding.

3. How many EM programs should I apply to with low or below average board scores?

Exact numbers depend on your full profile, but for a DO graduate with low scores:

• Applying to 35–60+ EM programs is typical, especially if:
  • You have exam failures.
  • You don’t have standout geographic or institutional ties.
• Make sure your list is heavy on:
  • DO-friendly programs.
  • Former AOA programs.
  • Community-based or less competitive geographic regions.
• Tailor each application (where possible) and use preference signals strategically.

4. Should I explain my low Step or COMLEX scores in my personal statement?

Only if:

• There is a clear, concise, and honest explanation (e.g., health issue, acute family crisis, late-diagnosed learning difference).
• You can pair the explanation with concrete evidence of subsequent improvement and maturity.

If you do address it:

• Keep it brief (1–3 sentences).
• Take responsibility.
• Emphasize growth, not excuses.

If there is no clear, constructive explanation, it may be better to focus the personal statement on your strengths, your fit for emergency medicine, and your clinical performance rather than revisiting the exam in detail.

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By understanding how your scores fit into the broader context of the emergency medicine residency match and deliberately building an application that amplifies your strengths, you can significantly improve your chances of success—even with a low Step 1 score or below average board scores as a DO graduate.