Essential Strategies for US Citizen IMGs with Low Step Scores in HBCU Residencies

Understanding the Challenge: Low Scores in the Context of HBCU-Affiliated Programs

For a US citizen IMG, a low Step score can feel like an almost insurmountable barrier to residency. When you add the complexity of being an American studying abroad and the unique landscape of HBCU residency programs, it can be hard to know where to focus your energy.

Yet many applicants with below average board scores do successfully match, including into HBCU-affiliated programs such as Meharry residency programs, Howard, Morehouse, and institutions partnering with HBCUs. The applicants who succeed share two traits:

1. They understand how program directors think about low Step 1 and Step 2 scores.
2. They design a deliberate, evidence-based strategy to offset and contextualize those scores.

This article is designed for US citizen IMGs who are:

• Worried about a low Step 1 score (including Pass with a marginal performance profile)
• Carrying below average board scores on Step 2 CK
• Interested in HBCU residency programs (internal medicine, family medicine, psychiatry, pediatrics, etc.)
• Looking for practical, step-by-step strategies to remain competitive and match despite these challenges

We’ll focus on how to strategically leverage your strengths, target HBCU-affiliated programs, and craft an application narrative that turns a liability into a compelling story of resilience, growth, and alignment with mission-driven institutions.

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How Programs View Low Step Scores for US Citizen IMGs

Before you can build a strategy, you need to understand the reality of how your application is screened and judged.

1. Why scores matter — especially for US citizen IMGs

Programs rely on board scores for multiple reasons:

• Filtering high application volumes
• Predicting likelihood of passing in‑training exams and specialty boards
• Roughly estimating an applicant’s test-taking ability and fund of knowledge

For US citizen IMGs and Americans studying abroad, programs often use higher cutoffs than they do for US MD/DOs because:

• They receive a large number of IMG applications
• They have limited interview spots
• They worry about visa issues (less for US citizens, but the “IMG” label still triggers more scrutiny)

However, being a US citizen IMG is an advantage compared to non-US IMGs: no visa issues, easier onboarding, fewer administrative barriers. HBCU programs that are dedicated to training physicians for underserved communities may be more open to holistic review, especially if you demonstrate strong alignment with their mission and communities they serve.

2. What “low” actually means

In the context of residency applications, “low” typically falls into these categories:

• Step 1 (Pass/Fail era)
  • Pass with multiple “Below Expectations” sections on the performance profile
  • Multiple failed practice exams documented in your MSPE or dean’s letter
• Step 2 CK
  • Score significantly below the national mean (~245–250 in recent years)
  • Typically < 225–230 for competitive programs
  • Failed attempts (any failure is a major red flag, but not always fatal)

When you read about matching with low scores or below average board scores, it usually refers to those with:

• One or more attempts
• Step 2 CK in the 210–225 range
• A Step 1 failure but subsequent pass
• Several borderline academic issues in medical school

HBCU-based or HBCU-affiliated programs may still consider such applicants if there is a compelling narrative and clear evidence of improvement, service, and fit.

3. The HBCU residency lens

HBCU-affiliated residency programs — such as Meharry residency, Howard, Morehouse, and those at institutions historically connected with HBCUs — often emphasize:

• Commitment to health equity and underserved communities
• Service to Black, Brown, and marginalized populations
• Resilience, persistence, and community engagement
• Diversity of backgrounds and experiences, including non-traditional paths

While these programs still care about Step scores (and many have filters), they are more likely than some others to:

• Practice holistic review
• Value your story, mission alignment, and service
• Appreciate candidates who overcame hardship, including academic setbacks

Your goal: make it easy for them to see that you are a mission-fit applicant who also has sufficient academic readiness.

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Academic Repair: Turning a Low Score into an Asset

If your scores are low, the single most important part of your strategy is demonstrating upward academic trajectory and reliable test-taking ability.

1. If you have not yet taken Step 2 CK

If you already have a low Step 1, your Step 2 CK becomes critical:

• Aim for a clear improvement relative to Step 1 performance indicators
• A solid Step 2 CK (≥ 230, ideally higher) can partially offset a weak Step 1 narrative
• For US citizen IMGs, many community and HBCU-related programs will seriously consider you with a strong Step 2 even if Step 1 is weak

Strategies to maximize Step 2 CK performance:

• Dedicated prep window:
  • 8–12 weeks of focused study if feasible
  • Protect as much uninterrupted time as possible
• Use high-yield resources intensely, not broadly:
  • UWorld (full Qbank, 1X through minimum; 2X if time)
  • NBME practice exams to track progress
  • Anki or similar spaced repetition tools for weak areas
• Formalize support:
  • Consider a tutor if you have a history of underperforming on standardized tests
  • Seek learning disability evaluation if you suspect ADHD, dyslexia, etc. (with documentation, you may qualify for accommodations)

If you are early enough in your timeline, Step 2 CK improvement is the single best way to shift your competitiveness.

2. If Step 2 is already low or you have multiple attempts

When both Step 1 and Step 2 CK are low or show failed attempts, your strategy must expand beyond test scores:

• In-training exam performance (once in residency) can prove improvement, but you must first get in the door
• Before residency, you can show academic reliability by:
  • Strong clinical grades, especially in core clerkships
  • Honors in sub-internships (sub-Is)
  • Excellent evaluations from US clinical rotations
  • High-quality letters commenting specifically on knowledge and growth
  • Research productivity (especially quality over quantity)

Some IMGs consider taking Step 3 early if already eligible. This can be a double-edged sword:

• Helpful if:
  • You’ve had low earlier scores but now can demonstrate clear improvement
  • You are applying to programs with concerns about board pass rates
• Harmful if:
  • You underestimate it and score low again or fail

For many US citizen IMGs with multiple low scores, Step 3 can be a strategic tool, but only if you prepare rigorously and have reason to expect a significantly better performance.

3. Translating “low scores” into a growth narrative

Programs are much more forgiving when your application shows:

• A clear turning point (e.g., you changed your study methods, sought help, were diagnosed with a learning issue and got accommodations)
• Consistent improvement after the low score
• A mindset of insight, responsibility, and growth, not excuses

Your application should present a coherent narrative:

“I struggled academically early on due to X, made Y changes, and since then you can see consistent improvement in my performance in Z areas.”

You will reinforce that story through:

• The personal statement
• The MSPE/dean’s letter (if supportive)
• Letters of recommendation explicitly commenting on your improvement and readiness for residency
• Any supplemental ERAS essays about challenges/adversity

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Targeting HBCU-Affiliated Programs Strategically

Not all programs are equally receptive to applicants with low scores. Intelligent targeting is essential, especially as an American studying abroad.

1. Understanding HBCU and HBCU-affiliated landscapes

HBCU-associated health systems typically include:

• Historically Black medical schools (e.g., Meharry Medical College, Howard University College of Medicine, Morehouse School of Medicine)
• HBCU-based hospitals and their residency programs
• Hospitals formally affiliated with HBCUs or their medical schools
• Community programs with long-standing missions serving minority and underserved populations

These programs often prioritize:

• Service to African American and underserved communities
• Applicants who show cultural humility and competence
• Prior community engagement and commitment to health equity

As a US citizen IMG, you can stand out if you:

• Demonstrate genuine connection to these missions (through experiences, not just words)
• Show understanding of structural racism, health disparities, and social determinants of health
• Highlight work in safety-net settings, free clinics, FQHCs, community health projects, etc.

2. Building a realistic program list

For matching with low scores, program selection is one of the biggest determinants of success.

Actionable steps:

1. Start with specialty choice:

   • More IMG-friendly: Internal Medicine, Family Medicine, Psychiatry, Pediatrics
   • More competitive/less forgiving of low scores: Dermatology, Orthopedics, ENT, Ophthalmology, etc.
   • If you have low scores, strongly consider focusing on IMG-friendly primary care specialties, especially for initial match.

2. Target IMG-friendly HBCU or mission-driven programs:

   • Investigate Meharry residency programs (IM, FM, Psych, etc.) and other HBCU-related residencies
   • Review program websites for:
     • “We consider international medical graduates” statements
     • Current or past residents who are IMGs
   • Use tools like FREIDA, program websites, and alumni networks to identify:
     • HBCU-affiliated programs with documented IMG histories
     • Community programs with strong underserved care focus

3. Segment your list:

   • High reach: University/HBCU programs that are academic or moderately competitive
   • Mid-range: Community and hybrid academic-community programs with some IMG intake
   • Safety: Strongly IMG-friendly community or rural programs in less popular locations

Given low Step scores, your list should be heavily weighted toward mid-range and safety categories, with a few reach HBCU programs where your mission fit is exceptional.

3. Using your US citizenship strategically

While you are an IMG, you are also not a visa risk. That matters.

In your application:

• Clearly indicate US citizenship in ERAS (no visa required)
• When emailing programs, mention:
  • “I am a US citizen IMG”
  • This can reassure programs that are cautious about visa processes but open to IMGs otherwise.

4. Leveraging geography and personal ties

HBCU-affiliated and mission-driven programs often value regional commitment. Strengthen your appeal by:

• Emphasizing:
  • You grew up, went to college, or have family in the region
  • Past experiences in the South, Southeast, or urban centers where HBCUs are located
• Applying strategically:
  • To programs in areas you have strong personal reasons to stay in
  • To HBCUs linked to your undergraduate institution, especially if you attended an HBCU

If you’re an American studying abroad but previously attended an HBCU for undergrad, this is a huge plus. Highlight:

• Former HBCU pre-med activities
• Service projects and organizations
• Mentors who can speak to your commitment and character

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Making Your Application Holistic and Mission-Aligned

Your goal is for HBCU and HBCU-affiliated programs to see you not as “the low score applicant,” but as:

“The US citizen IMG with an incredible story of resilience, community commitment, and proven clinical strength — who also happens to have some earlier academic struggles that they have clearly overcome.”

1. Personal statement: Honest, focused, and mission-driven

For low Step score strategies, your personal statement is a prime place to control the narrative.

Key principles:

• Be honest but concise about low scores
  • Briefly mention the context and what you learned
  • Avoid blaming others or dwelling excessively
• Emphasize growth
  • Describe specific changes in your study habits, time management, or mental health approach
  • Show how you now function effectively in demanding clinical environments
• Connect to HBCU missions
  • Describe experiences with underserved communities
  • Reference work that aligns with health equity, racial disparities, community-based care
• Highlight identity and perspective (where appropriate):
  • If you identify as Black, from a marginalized community, or from a rural or low-resource background, explicitly connect that perspective to your desire to train at an HBCU-linked program
  • If you’re not from those backgrounds, show cultural humility, allyship, and a track record of engagement, rather than superficial or performative statements.

2. Letters of recommendation: Your most powerful validators

For an applicant with below average board scores, strong letters can outweigh a lot of numerical weakness.

Prioritize getting letters that:

• Come from US-based faculty (especially at teaching hospitals)
• Are in your target specialty
• Specifically address:
  • Clinical reasoning and medical knowledge (“performs at or above the level of our US grads”)
  • Work ethic and reliability
  • Improvement over time (“significant growth since early struggles”)
  • Mission alignment with underserved and minority health

If you can secure a letter from an attending connected to HBCU or underserved community programs, even better.

Practical tip:
Ask your letter writers directly:

“Given my low Step scores, would you feel comfortable writing a strong, supportive letter that speaks to my current clinical ability and readiness for residency?”

You want authors who say yes without hesitation.

3. Clinical experiences and electives: Show performance, not promise

For US citizen IMGs, US clinical experience (USCE) is critical, especially at sites that:

• Serve underrepresented or underserved populations
• Are affiliated with HBCUs or safety-net hospitals

Aim for:

• Sub-internships (sub-Is) or acting internships in your specialty
• Rotations where you are evaluated closely and can earn strong letters
• Settings aligned with health equity and minority health

During these rotations:

• Be early, prepared, and proactive
• Ask for mid-rotation feedback and act on it
• Let faculty know you value detailed written evaluations to support your application

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Application Tactics: ERAS, Signaling, Communication, and Interviewing

Once you’ve built your academic and experiential foundation, it’s time to execute the application phase strategically.

1. ERAS application details that matter for low-score applicants

• Supplemental ERAS (if available):
  • Use “diversity,” “adversity,” or “other impactful experiences” prompts to:
    • Briefly contextualize your academic challenges
    • Emphasize your resilience and growth
    • Highlight your work with underserved and minority communities
• Experiences section:
  • Give most meaningful status to:
    • Community health work
    • Projects related to health disparities, Black health, or underserved care
    • Leadership roles in culturally relevant or service-oriented organizations
• Additional degrees or certifications:
  • MPH, MHA, or certificates in health equity, population health, or global health can support your credibility

2. Signaling interest in HBCU and mission-driven programs

In any signaling system (formal or informal):

• Prioritize HBCU and HBCU-affiliated programs that:
  • Are IMG-accepting
  • Have strong community missions
• Consider emailing programs (brief, respectful messages) when:
  • You have a genuine, specific reason for interest (e.g., past work in that city, mentors connected to the program, prior rotations there)
  • You want to clarify that you are a US citizen IMG with a strong commitment to their mission

Sample email (adapted):

Dear Dr. [Program Director],

I am a US citizen international medical graduate from [School] applying to your [Specialty] residency program. I am particularly drawn to [Program Name] because of its commitment to serving [specific underserved population/region] and its connection to [HBCU or mission].

My clinical experiences in [clinic/hospital/community] have focused on [brief description], and I hope to continue this work in residency. I recognize that my earlier board scores are below average, but since that time I have [improvement: strong Step 2, excellent clinical evaluations, research, etc.]. My recent evaluations and letters reflect my current readiness for residency.

Thank you for your consideration of my application.
Sincerely,
[Name], US citizen IMG

Keep it short, specific, and framed around mission and growth.

3. Interview performance: Owning your story

If you secure interviews at Meharry residency programs or other HBCU-affiliated sites, you must be ready for questions like:

• “Can you walk me through what happened with your Step scores?”
• “How have you grown since those challenges?”
• “What drew you to HBCU-based training?”

Answer framework:

1. Briefly describe the issue
   • “I struggled with standardized tests during my early exam phase, and my Step 1/2 score reflects that.”
2. Acknowledge responsibility
   • Avoid blaming; show maturity.
3. Describe changes made
   • New study strategies, time management, addressing mental health, tutoring, etc.
4. Show objective evidence of improvement
   • Better clinical evaluations, improved exam performance, Step 3 (if taken), research productivity.
5. Reframe as strength
   • Emphasize empathy for struggling patients, resilience, and an understanding of how to persevere.

When asked about interest in HBCU residency programs:

• Reference:
  • Their mission statements
  • Their service populations
  • Your relevant experiences
• Make the connection explicit:
  • “Given my background in [X community experience], I believe I can contribute meaningfully to [Program’s] work addressing [Y disparities].”

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Long-Game Planning: If You Don’t Match the First Time

Even with strong strategies, some US citizen IMGs with low Step scores may not match on the first attempt. Planning for this possibility increases your chances in the next cycle.

1. Strengthening your profile in a gap year

If you go unmatched:

• Seek positions as:
  • Research assistant (especially in health equity, primary care, mental health)
  • Clinical research coordinator at an academic or safety-net institution
  • Preliminary or transitional year if available (and strategically chosen)
• Focus on:
  • Publishes or abstracts (even case reports)
  • Building new letters of recommendation
  • Maintaining or enhancing clinical exposure
• Consider:
  • A 1-year MPH with emphasis on health disparities or community health, especially at a university with connections to HBCUs or safety-net hospitals

2. Reapplying more strategically

On a reapplication:

• Tighten your program list even more toward:
  • IMG-friendly
  • Community-based
  • Underserved mission-driven programs
• Update:
  • Personal statement with new concrete achievements
  • CV with any publications, new roles, leadership
• Highlight:
  • How you used the last year to grow, remain clinically engaged, and support underserved communities

Programs notice persistence when it’s paired with substantive improvement, not when it’s just repeated applications without growth.

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FAQs: Low Step Score Strategies for US Citizen IMGs in HBCU-Affiliated Programs

1. Can I still match into an HBCU-affiliated program with a low Step 1 or Step 2 score?

Yes, it is possible, especially for US citizen IMGs, but not guaranteed. Your chances improve if:

• You demonstrate clear academic improvement (strong Step 2 or Step 3, better clinical performance)
• You have strong US letters emphasizing readiness and clinical strength
• You show genuine alignment with HBCU and health equity missions
• You apply broadly to IMG-friendly, underserved-focused programs, not only HBCUs

The bar can be high, but holistic programs will consider you if your overall profile is compelling.

2. Should I mention my low scores directly in my personal statement?

Yes, but briefly and strategically. For many applicants with below average board scores:

• A short, honest explanation plus a focus on what changed and how you improved is better than ignoring it
• Do not spend the majority of your statement on this topic; emphasize your strengths, growth, and mission alignment

If your dean’s letter already thoroughly covers your struggles and improvement, you can be even more concise in your personal statement.

3. Is taking Step 3 before applying helpful for matching with low scores?

It can be, but only in select situations:

Helpful when:

• You have low or failed earlier scores but are now confident you can significantly outperform your prior performance
• You have the time and support to prepare thoroughly
• You are targeting programs particularly concerned about board pass rates

Risky when:

• You are still not well-prepared for standardized exams
• Another low or failed score would further damage your application

Discuss this decision with advisors who understand your academic pattern.

4. As an American studying abroad, how can I best stand out to Meharry and other HBCU residency programs?

To stand out:

• Highlight any prior connection to HBCUs, African American communities, or underserved populations
• Demonstrate sustained engagement, not just short-term or superficial experiences
• Secure letters from mentors who can speak to your commitment to health equity and community service
• Clearly state why HBCU-affiliated training specifically — not just “I want to help underserved people,” but how your background and goals align with their particular mission and patient population

By combining academic repair, a mission-driven narrative, and smart program targeting, many US citizen IMGs with low Step 1 or Step 2 scores have successfully matched — including into HBCU-affiliated residency programs. Your scores are a part of your story, but they do not have to be the final chapter.