Overcoming Low Step Scores: A DO Graduate's Guide to Med-Psych Residency

Understanding the Challenge: Low Scores as a DO Applicant to Med-Psych

Applying to a Medicine-Psychiatry combined program as a DO graduate with a low Step 1 (or Level 1) score feels intimidating—but it does not automatically close the door on a med psych residency. Programs absolutely look at board performance, yet they also care deeply about maturity, trajectory, fit, and evidence that you understand the dual nature of medicine psychiatry combined training.

For DO graduates, there are additional layers:

• Historic bias toward MD applicants at some academic centers
• Variable familiarity with COMLEX scores among internal medicine and psychiatry faculty
• Fewer DO role models in combined medicine-psychiatry programs

At the same time, you have real strengths: holistic training, heavy exposure to psychosocial aspects of care, and experience integrating mind–body frameworks. Those strengths align very well with med psych residency.

This article will walk through a strategic, step-by-step plan to maximize your chances of an osteopathic residency match in Medicine-Psychiatry despite a low Step 1 or below average board scores. We’ll focus on what you can still control: your USMLE/COMLEX strategy, application narrative, clinical performance, networking, and program selection.

---

Step 1 and COMLEX: Frame, Mitigate, and Move Forward

A low Step 1 (or Level 1) is not the end of your application—it’s a data point. Your goal is to show programs three things:

1. You understand what went wrong
2. You’ve taken concrete steps to improve
3. Your later performance trends upward

Clarify What “Low” Means in Context

“Low” is relative. For a DO graduate applying to med psych:

• Below ~215–220 on Step 1 (or COMLEX Level 1 < 500) is often considered below average for academic IM/psych programs.
• Some combined medicine-psychiatry residencies are more forgiving, especially at community-focused or newer programs.

If Step 1 is now pass/fail for you, but you failed on the first attempt or just barely passed, that still matters. A fail or marginal pass can be a red flag—but it’s a manageable one if you show clear recovery.

Maximize Step 2 CK and Level 2 CE

For applicants with a low Step 1, Step 2 is your biggest opportunity to change the narrative.

Priority actions:

• Take Step 2 / Level 2 early enough to have your score back before ERAS submission. Programs will look closely at this.
• Aim for a clear jump in performance—ideally into or above the national mean. For someone with a low Step 1, even a 10–15 point “step up” is meaningful.
• Tailor your prep to patterns of weakness. If your Step 1/Level 1 failure or low score was driven by test-taking anxiety, timing, or weak foundations, address those specifically:
  • Work with a tutor or test-prep coach
  • Use full-length practice tests and strict timing
  • Practice high-yield question blocks in mixed, random mode

If you already have below average board scores on both Step 1 and Step 2, your strategy shifts:

• Emphasize clinical excellence, strong letters, and fit with the med psych mission
• Use your personal statement and MSPE/Dean’s letter to highlight resilience and upward trends in clerkship grades
• Consider taking an additional exam (e.g., a subject exam or shelf) under monitored conditions through your school and having performance documented

Addressing a Fail or Low Score in Your Application

You do not need to write a full-page apology letter in your personal statement, but you must have a mature, concise explanation ready—for your ERAS application, interviews, and any supplemental communication.

Key principles:

• Own the result. Avoid blaming the exam or unfairness, even if circumstances were hard.
• Identify specific factors (e.g., health, family crisis, poor study strategy, untreated ADHD/anxiety) only if you’re comfortable sharing and it’s relevant.
• Highlight concrete corrective actions:
  • Changed study methods (e.g., daily questions, spaced repetition)
  • Used disability services/testing accommodations when appropriate
  • Sought mental health care or academic counseling
• Show outcome data. “After these changes, I improved my NBME subject exams and scored X on Step 2 CK…”

Programs in Medicine-Psychiatry are often particularly attuned to narratives of resilience, introspection, and growth. Framed correctly, overcoming a low Step 1 score can actually strengthen your story as someone who understands vulnerability, failure, and recovery—key themes in psychiatry and chronic medical illness.

---

Building a Med-Psych Identity: Beyond the Numbers

For a DO graduate with matching with low scores concerns, your identity as a future med psych physician becomes your differentiator. You want programs to think: “Even if their Step 1 score is low, this applicant is clearly meant for Medicine-Psychiatry.”

Demonstrate Genuine Commitment to Medicine-Psychiatry Combined Training

Programs want to avoid people who see med psych as a “backup” to internal medicine or psychiatry. You need to show that medicine psychiatry combined training is your first-choice pathway.

Consider these ways to build a cohesive med psych profile:

1. Integrated Clinical Experiences

   • Seek rotations or electives where you can work at the interface of IM and psych:
     • C-L (consult-liaison) psychiatry
     • Integrated primary care/behavioral health clinics
     • Addiction medicine in a medical inpatient unit
     • Geriatrics with strong focus on dementia and behavioral disturbances
   • During these rotations, explicitly ask attendings for teaching about how medicine and psychiatry intersect.

2. Scholarly Work with a Med-Psych Flavor

   • Quality improvement or research addressing:
     • Depression and diabetes management in primary care
     • Cardiometabolic side effects of antipsychotics
     • Hospital readmissions among patients with serious mental illness
     • Management of substance use disorders on medical wards
   • A single case report or poster on a patient with both complex medical and psychiatric illness can go a long way—especially at regional or national osteopathic or psychiatry meetings.

3. Longitudinal Experiences

   • Volunteer or work with:
     • Homeless clinics
     • Assertive community treatment (ACT) teams
     • Chronic disease management programs that integrate behavioral health
   • Sustain these experiences for months rather than a single one-off week. Combined programs love evidence of commitment over time.

Use Your Osteopathic Background as a Strength

As a DO graduate, your training naturally emphasizes holistic care, biopsychosocial models, and the integration of mind, body, and environment—all perfectly aligned with med psych.

You can highlight:

• Osteopathic principles that frame your approach:
  • “The body is a unit” → integration of physical and mental health
  • “Structure and function are interrelated” → how chronic pain, somatic symptoms, and mental health interact
• Osteopathic manipulative treatment (OMT) in:
  • Chronic pain and somatic symptom disorders
  • Tension headaches, fibromyalgia, and associated depression/anxiety
• Reflections from your OMM labs and rotations about seeing patients’ mental distress expressed through physical complaints.

This is especially compelling in your personal statement and in interviews, where you can articulate how your DO background makes you particularly suited to Medicine-Psychiatry combined training.

---

Optimizing Clinical Rotations, Letters, and Personal Statements

With low Step scores, your clinical and narrative components become the core of your application. Programs in med psych are often smaller, more personalized, and very attentive to letters and fit.

Be Strategic with Core Clerkships and Sub-Internships

Combined medicine psychiatry residencies will scrutinize your performance in:

• Internal Medicine
• Psychiatry
• Sub-internships or acting internships (AI) in IM, psych, or combined settings

You want your grades and comments here to tell a story of reliability, curiosity, and patient-centered care.

Actions:

• Front-load your effort in IM and psych clerkships:
  • Read about your patients every day
  • Pre-round early; know your patients thoroughly
  • Ask for mid-rotation feedback and actually implement it
• Choose at least one sub-I in:
  • Internal Medicine (preferably inpatient)
  • Psychiatry (especially C-L psych or inpatient with medically complex patients)
• Perform at “intern level”:
  • Volunteer to write full notes, manage orders under supervision, call consults
  • Show you can think through both psych and medical differentials

Strong narratives in your clerkship comments—a “workhorse,” “dependable,” “strong grasp of whole-patient care”—help offset below average board scores.

Get Letters That Explicitly Address Your Fit for Med-Psych

The ideal letter writer mix for a Medicine-Psychiatry combined application:

1. One strong Internal Medicine attending (preferably at an academic site)
2. One strong Psychiatry attending who has seen you with medically complex or dual-diagnosis patients
3. A third letter from:
   • Med-Psych faculty (ideal but rare)
   • C-L psychiatrist
   • Primary care physician with integrated behavioral health experience
   • Research or QI mentor in a med psych-related project

If a writer knows your Step difficulties, ask if they can comment directly on your clinical judgment, reliability, and ability to keep up with the cognitive demands of residency, to reassure programs.

Give letter writers:

• A concise CV
• A one-page “med psych story” (why this path, your growth, your scores context)
• Specific examples of patients or projects you worked on with them

Crafting a Personal Statement that Makes Sense of Low Scores

Your personal statement for a med psych residency should do three things:

1. Tell a coherent story of why Medicine-Psychiatry combined is your path
2. Show how your experiences align with that path
3. Briefly, maturely contextualize your low Step 1 or below average board scores (if appropriate)

A practical structure:

• Opening vignette of a patient where physical and mental illness were tightly linked and changed how you saw medicine
• Middle: Your longitudinal interest—rotations, volunteer work, research—leading you toward medicine psychiatry combined training
• Bridge section: A short, professional reflection on your exam history:
  • One paragraph at most, unless there are major complexities
  • Focus on insight and growth, not excuses
• Closing: The future—what kind of med psych physician you aspire to be and how combined training is essential to that vision

Avoid:

• Rehashing your entire life story
• Overemphasizing your low Step score
• Sounding like med psych is a fallback because you worry about matching with low scores in categorical fields

You want program directors to finish your statement thinking: “Regardless of the numbers, this person clearly belongs in med psych.”

---

Application Strategy: Program Selection, Signaling, and Networking

Even the best narrative and letters won’t help if your application strategy is misaligned. With below average board scores, especially as a DO graduate, your program list and networking become crucial.

Understand the Med-Psych Landscape

Medicine-Psychiatry combined programs are:

• Relatively few in number
• Often academically oriented
• Typically small (2–4 residents per year), which means fewer total spots

Implication: You should not apply exclusively to med psych programs if your Step 1 is low and Step 2 is average or slightly below. Instead:

• Apply broadly to:
  • Medicine-Psychiatry combined programs that seem DO-friendly
  • Categorical Psychiatry programs
  • Categorical Internal Medicine programs (especially community or university-affiliated community)
• Consider your geographic flexibility. Being willing to move opens more options.

Research DO-Friendliness and Score Expectations

For each med psych residency and related categorical program:

• Review:
  • Program websites for current/past residents’ backgrounds (DOs? MD/DO mix?)
  • FREIDA and residency explorer tools (if accessible) for typical board score ranges
• Look for:
  • Prior DO graduates on the resident list
  • Emphasis on holistic care, underserved populations, addiction, C-L psychiatry—domains often more open to diverse metrics
• If you have a very low Step 1 (e.g., <210, or COMLEX <450) and only modest Step 2 improvement:
  • Deprioritize the most competitive academic centers unless there’s a strong connection or research niche fit

Consider categorizing programs:

1. Reach: Top academic centers with med psych programs and high score ranges
2. Target: DO-friendly, mid-range score expectations, mission-driven programs
3. Safety: Primarily categorical psychiatry and internal medicine programs known to be more holistic in evaluation

For a DO graduate with matching with low scores worries, a robust list might include:

• All realistic med psych programs that
  • Have DOs in current or recent classes
  • Emphasize underserved care or integrated care
• 30–50 categorical psychiatry programs at varying competitiveness levels
• 20–40 categorical internal medicine programs, with focus on community or university-affiliated community settings

The exact numbers vary with your full profile, but breadth is safer when your scores are a liability.

Use Networking and Signals Wisely

Because Medicine-Psychiatry combined programs are small, personal contact can have outsized impact.

• Email programs thoughtfully:
  • Brief introduction: who you are, DO background, specific interest in med psych
  • One or two reasons you’re interested in that program (not generic)
  • Politely ask if there are opportunities to:
    • Attend a virtual open house
    • Join a grand rounds
    • Talk briefly with a current resident
• Attend virtual events:
  • Take notes, ask a 1–2 thoughtful questions that show your understanding of combined training
  • Follow up with a short thank-you email referencing something specific
• Use mentors:
  • If your school has faculty with connections to med psych or psych/IM programs, ask them to send brief advocacy emails.
• If your school allows program signals (if in use for your cycle):
  • Priority-signal a limited number of med psych programs where your fit is strongest and DO-friendliness seems highest.
  • Use remaining signals for categorical psych/IM programs that value integrated care or underserved populations.

Your aim is to convert yourself from a “borderline on paper” applicant into a “known quantity with a compelling story.”

---

Managing Risk and Planning Backup Paths

Even with a well-executed strategy, the osteopathic residency match is never guaranteed—especially for a small, specialized field like med psych. A realistic, layered plan protects your long-term goal of practicing at the intersection of medicine and psychiatry.

Layer 1: Primary Aim – Medicine-Psychiatry Combined

• Apply to every realistic med psych program that:
  • Has a track record with DOs, or
  • Is strongly aligned with your interests (integrated care, C-L, addiction, chronic disease + mental health)
• Invest extra effort in:
  • Tailored personal statements for these programs
  • Direct contact through emails and virtual events

Layer 2: Strong Secondary Options – Categorical Psychiatry and Internal Medicine

Even if you ultimately want a med psych identity, you can still build a dual-skill career from categorical training:

• Categorical Psychiatry:
  • Later add medical training via:
    • Additional IM rotations/electives
    • Addiction medicine or psychosomatic medicine (C-L) fellowships
    • Collaborative care/integrated primary care work
• Categorical Internal Medicine:
  • Emphasize psychosocial care in chronic disease clinics
  • Consider addiction medicine, palliative care, or psychosomatic medicine collaborations
  • Work in integrated behavioral health environments

Programs may also appreciate that you’re not “med psych or bust” but have a realistic, flexible vision.

Layer 3: If You Don’t Match – Immediate Next Steps

If you go unmatched:

1. Participate fully in SOAP with a broad strategy:
   • Categorical psych and IM
   • Transitional/preliminary medicine years
2. Seek a gap-year plan that strengthens your application:
   • Research or QI in integrated care, C-L psychiatry, or chronic disease + mental health
   • Full-time clinical role (e.g., research coordinator, mental health clinic support)
   • Additional coursework or a certificate in public health, addiction studies, or integrated care, if feasible
3. Reassess exam strategy:
   • If you underperformed on Step 2 or Level 2 as well, consider expert tutoring or an academic support program.
4. Stay connected to the med psych world:
   • Continue publishing/postering, joining interest groups (APA, ACP, Academy of Consultation-Liaison Psychiatry), and deepening your combined focus.

Over 2–3 years, some applicants successfully re-enter the match with a stronger profile and ultimately reach medicine psychiatry combined or similarly integrated roles.

---

FAQs: DO Graduate with Low Scores Applying to Medicine-Psychiatry

1. Is it realistic to match into a Medicine-Psychiatry combined program with a low Step 1 score as a DO?

It’s challenging but not impossible. Your chances depend heavily on:

• How low the score is and whether there was a fail
• Your Step 2 / Level 2 performance (improvement is key)
• Strength of your clinical evaluations and letters in IM and psych
• Evidence of sustained interest in medicine psychiatry combined care

For a DO graduate, focusing on DO-friendly med psych programs, building a strong identity as an integrated-care physician, and applying broadly (including categorical IM and psych) gives you a realistic pathway.

---

2. Should I take Step 2 CK if I already have a strong COMLEX Level 2, or can I rely on COMLEX alone?

If you are targeting Medicine-Psychiatry combined programs, especially those in academic centers, taking Step 2 CK is usually advantageous. Not all PDs are fully comfortable comparing COMLEX-only scores across applicants. A solid Step 2 score:

• Provides reassurance after a low Step 1 or Level 1
• Puts you on the same metric as MD applicants
• Demonstrates that you can perform on a widely used exam

If your school timing and finances allow, and you’re prepared to score at least in the average range or better, Step 2 CK is generally worth it.

---

3. How directly should I address my low Step 1 score in my personal statement and interviews?

Be brief, honest, and forward-looking.

• In the personal statement, 2–4 sentences is usually enough:
  • Acknowledge the result
  • Identify one or two key learning points
  • Highlight subsequent improvement (especially Step 2 and clinical performance)
• In interviews, be prepared with a concise answer:
  • Own the responsibility
  • Avoid oversharing or heavily emotional narratives unless clearly relevant
  • Emphasize resilience and the skills you developed (time management, help-seeking, coping strategies)

Program directors want to see insight, not excuses.

---

4. If I end up in a categorical psychiatry or internal medicine residency, can I still build a med psych career?

Yes. Many physicians with strong med psych identities are not formally med psych trained. You can:

• In Psychiatry residency:
  • Seek extra rotations with medically ill patients (C-L, inpatient med unit consults)
  • Pursue addiction medicine, psychosomatic medicine, or collaborative care exposures
• In Internal Medicine residency:
  • Focus on psychosocial aspects of chronic diseases (diabetes, CHF, COPD)
  • Work closely with integrated behavioral health teams
  • Pursue addiction medicine fellowship or develop expertise in managing mental health within primary care
• Throughout your career, choose practice settings that integrate medical and psychiatric care.

A low Step 1 score or any below average board scores do not prevent you from practicing at the powerful intersection of medicine and psychiatry; they simply shape your route and require more strategic planning.