Strategies for Matching with Low Step Scores in EM-IM Residency

Understanding the EM–IM Landscape When You Have Low Scores

Emergency Medicine–Internal Medicine (EM IM) combined residency programs are small, competitive, and relatively niche. When you add a low Step 1 score or below average board scores into the mix, the application process can feel daunting—but not impossible.

The key is to understand:

• How programs use scores
• What matters besides scores
• How to present your overall profile in the strongest possible way

For clarity, “low Step score” in this guide generally means:

• USMLE Step 1: historically <220, but now often translated into “pass on second attempt,” “barely passed,” or “marginal basic science performance” since it is pass/fail
• USMLE Step 2 CK: <230–235 for EM/IM combined programs (exact thresholds differ by program)
• COMLEX equivalents: Below national mean or significant score drop/failure

This guide focuses specifically on Emergency Medicine–Internal Medicine combined residency and strategies for matching with low scores—not generic advice that ignores the distinct nature of EM IM training.

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How EM–IM Programs View Board Scores

1. Why Scores Matter in EM–IM

EM–IM residents must succeed in:

• Internal Medicine In-Training Exams (IM-ITE)
• Emergency Medicine In-Training Exams (EM-ITE)
• ABIM and ABEM board certification exams

A history of low or borderline scores raises natural questions for program leadership:

• Can this applicant handle the academic rigors of two residencies in one?
• Will they pass both boards on the first attempt?
• Will they require disproportionate support or remediation?

However, many EM–IM program directors also recognize:

• Board performance is only one dimension of ability.
• Step scores correlate imperfectly with clinical performance.
• Some applicants with low Step scores have exceptional clinical skills, resilience, and work ethic.

Your job is to acknowledge the concern and directly address it with evidence and planning.

2. How EM–IM Uses Scores Practically

Most EM–IM programs will:

• Screen for minimum score cutoffs (often higher for Step 2 CK than Step 1 pass/fail)
• Look at:
  • Number of attempts
  • Upward vs downward trends
  • Timing (did you improve after a leave, remediation, or dedicated study period?)

Common patterns and what they signal:

• Low Step 1, stronger Step 2 CK (≥10–15 point improvement; or from fail to solid pass)
  → You demonstrated growth and adaptation. This is often seen as a positive trajectory.

• Borderline Step 1, borderline Step 2 CK, but strong clinical evaluations & letters from EM/IM
  → Raises concern, but strong clinical evidence may offset concerns if the narrative is well framed.

• Multiple exam failures
  → Much more challenging. Matching EM–IM is possible but requires a hyper-targeted list, outstanding mentorship, and a candid, well-structured explanation.

• DO applicants relying on COMLEX only
  → Some EM–IM programs strongly prefer or require USMLE. For low scores, not having USMLE can be an added barrier, so your strategy may differ (see FAQs).

Understanding these patterns helps you decide whether to:

• Double down on EM–IM
• Apply to EM–only or IM–only as well (or instead)
• Use a “reach/realistic/safety” approach among EM–IM, EM, and IM

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Strategic Self-Assessment: Are EM–IM Programs a Realistic Fit?

Before crafting your application, you need an honest, data-informed self-assessment.

1. Evaluate Your Academic Profile

Create a brief academic snapshot:

• Step 1: pass/fail, attempts, narrative (e.g., “pass on second attempt after personal/health issue”)
• Step 2 CK: score, attempts, trend
• Step 3 (if taken): score and trend
• Clerkship performance:
  • EM rotation grades
  • IM rotation grades
  • Sub-Is or acting internships in EM or IM
• Shelf exam performance, especially EM & IM (if your school reports it)

Then, classify your profile:

• Category A: Low Step 1, but average/strong Step 2 CK and strong clinical performance

  • You are still a viable EM–IM candidate.
  • Focus strategy on narrative, letters, and fit.

• Category B: Low Step 1 and low Step 2 CK, but strong clinical performance and clear EM–IM motivation

  • You have an uphill climb, but it’s not impossible.
  • Strategy: high-volume applications, broad specialty mix, and clear remediation plan.

• Category C: Multiple exam failures, limited improvement, and mixed clinical performance

  • EM–IM combined may be very high risk.
  • Strategy: frank mentoring with advisors; consider IM-only or community EM, transitional year, or other paths.

2. Clarify Why EM–IM Specifically

EM–IM combined programs are not simply “EM plus IM” to hedge against low scores. Program directors want to see:

• A clear, mature understanding of dual training
• Career goals that require both specialties, such as:
  • ED observation unit leadership
  • ED-based critical care or step-down units
  • ED–hospitalist hybrids / nocturnist leadership
  • Rural or resource-limited settings where you cover ED and inpatient
  • Administrative roles bridging ED and medicine services

If your interest feels vague or opportunistic (e.g., “more options if I can’t match EM”), programs will sense it—especially if your scores are on the lower side.

Action step:
Write a one-sentence purpose statement:

“I want EM–IM combined training because I plan to _________, and this dual training uniquely prepares me by _________.”

This statement will shape your personal statement and interviews.

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Application Tactics: Matching EM–IM with Low Scores

1. Targeting Programs Strategically

The EM IM combined world is small—only a limited number of programs nationwide. With low Step scores, you must be strategic and broad:

• Apply to all EM–IM programs unless you have a compelling reason to exclude some (e.g., geographic immobility).
• Simultaneously apply to:
  • Categorical EM programs
  • Categorical IM programs
  • Possibly EM/IM/CC (triple board) only if your academic record supports it; otherwise, it may be too competitive.

For applicants with low Step 1 or low Step 2 CK, consider:

• Heavier emphasis on IM programs if your EM letters are weaker or if you have a stronger IM narrative.
• More EM programs if you have strong SLOEs (Standardized Letters of Evaluation) and clear EM performance strengths, accepting that EM–IM is a reach.

Ask your advising dean or EM/IM faculty mentor to help categorize programs into:

• Reach (very competitive; high average scores)
• Realistic (slightly above your profile but plausible)
• Safety (community or less competitive IM or EM programs)

Your “safety” category may not include EM–IM combined programs at all—and that’s okay. It’s about securing a training position, not just an ideal one.

2. Building a Compelling Application Around Low Scores

a. Personal Statement Strategy

Your personal statement for emergency medicine internal medicine combined must do three things:

1. Explain your interest in EM–IM clearly and specifically
2. Demonstrate insight and resilience around your exam performance (briefly but directly)
3. Highlight strengths that matter for dual training (adaptability, work ethic, longitudinal thinking)

Tips:

• Do not lead with your scores.
• Do include a short, factual paragraph if your low scores or failures would otherwise be a “mystery”:
  • Own the difficulty without dramatizing it.
  • Provide context (health, life events, study strategy errors) without sounding like you’re making excuses.
  • Emphasize what changed: specific shifts in study habits, time management, mental health support, or resource use.
  • Add a forward-looking sentence linking these changes to future success in a rigorous EM–IM curriculum.

Example (for a low Step 1 score, improved Step 2 CK):

During my pre-clinical years, I struggled to translate knowledge into standardized test performance and my Step 1 score reflects that. After working closely with our learning specialist, I overhauled my approach to spaced repetition, question-based learning, and test-day anxiety. The improvement in my Step 2 CK performance and my shelf exams mirrors these changes, and I am confident in my ability to meet the academic demands of combined EM–IM training.

The goal is to show growth and control, not helplessness.

b. Letters of Recommendation: Your Most Powerful Counterweight

For matching with low scores in EM–IM, strong letters are often more influential than marginal score differences.

Aim for:

• 2 strong EM letters (ideally SLOEs from EM rotations, including at academic centers)
• 1–2 strong IM letters (ideally from inpatient or ICU rotations)

What makes a letter “strong” for EM–IM?

• Comments on your ability to:
  • Manage acute and undifferentiated patients
  • Think longitudinally about chronic disease and disposition
  • Function in high-volume, high-acuity settings
  • Communicate clearly with teams and patients
• Explicit statements like:
  • “I would rank this student in the top X% of students I have worked with over the past Y years.”
  • “I have no reservations about this applicant’s ability to handle the demands of a combined EM–IM program.”

If your scores are low, ask your letter writers directly:

“Given my lower board scores, would you feel comfortable strongly recommending me for EM–IM combined training, where there may be concerns about academic rigor?”

You want letters that proactively reassure PDs about your potential.

c. CV and Experiences: Show EM–IM Alignment

Highlight experiences that naturally align with emergency medicine internal medicine:

• Longitudinal care of complex patients in student-run clinics
• Research or QI in:
  • Sepsis
  • Heart failure
  • COPD exacerbations
  • ED flow and throughput
  • Transitions of care (ED-to-floor or ED-to-ICU)
• Volunteer work in:
  • Underserved EDs or urgent care
  • Rural or resource-limited settings
• Leadership roles that show:
  • Systems thinking
  • Cross-disciplinary collaboration

When you have below average board scores, program directors will look more intently at everything else to see if you truly fit the EM–IM world.

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Addressing Low Scores Directly: Interviews, Signals, and Red Flags

1. Using Signals and Communication Strategically

In the era of preference signaling (if applicable in your cycle):

• Use a signal on your top EM–IM programs even if you know you’re a longshot.
• Use some signals on EM and/or IM programs where:
  • Your mentors have connections
  • You have regional ties
  • Your application otherwise fits their mission

For low-score applicants, personalized outreach (where appropriate and allowed) can matter:

• A brief, polite email to the PD or PC:
  • Reiterating strong interest in EM–IM
  • Highlighting specific ties to their program, city, or patient population
  • Not rehashing your entire Step narrative—keep it short and focused on fit

2. Interview Preparation: Framing Your Story

You should expect an interview question like:

• “Tell me about your Step 1/Step 2 score.”
• “I see you struggled early on—what changed?”
• “Given the demands of EM–IM, why should we feel confident about your future exam performance?”

Your response framework:

1. Acknowledge the concern briefly and factually.
2. Contextualize without over-explaining or blaming.
3. Describe what you changed. Focus on process, not just outcome.
4. Provide evidence of improvement (Step 2 CK, shelves, in-training exam if applicable).
5. Connect it to EM–IM success (discipline, resilience, self-reflection).

Example answer:

During my pre-clinical years, I underestimated how much deliberate practice with questions and spaced repetition mattered, and I relied too heavily on passive review. That was a major factor in my low Step 1 score. I took that setback seriously: I met with our academic support team, changed my schedule to prioritize daily question blocks and weekly self-assessment, and addressed test anxiety with a counselor. You can see the result in my Step 2 CK and my EM and IM clerkship evaluations, which reflect stronger knowledge application. Those changes are now habits, and I plan to use the same structured approach during residency to prepare for the EM and IM boards.

Your tone should be:

• Calm
• Mature
• Solution-focused
• Free of bitterness or self-pity

3. Avoiding Common Red Flags

With low Step scores, you must minimize other risk factors:

• Unexplained gaps in training → Always provide clear, concise explanations.
• Thin or generic personal statement → Shows lack of reflection; especially harmful in EM–IM.
• No clear EM–IM exposure or understanding → Programs may doubt your commitment.
• Overemphasis on “I want options” as the reason for EM–IM → Suggests indecision, not fit.
• Inconsistent professionalism (late responses, incomplete forms, mismatched program names in PS) → Especially damaging when your academic record already raises concerns.

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Long-Game Planning: If You Don’t Match or Need More Time

Despite best efforts, some applicants with low Step 1 scores or below average board scores will not match EM–IM on the first try. Planning for this possibility is strategic, not pessimistic.

1. Parallel Planning: EM, IM, and EM–IM

For many applicants, a parallel planning approach is wise:

• Apply EM–IM, EM, and IM simultaneously.
• Be honest with yourself: If EM–IM interviews do not materialize, be prepared to rank your EM and IM lists thoughtfully instead of holding out unrealistically.

If you match IM or EM only:

• You can still shape a career that looks a lot like EM–IM:
  • IM + ED moonlighting later
  • EM + strong relationships with hospitalist or ICU teams
  • Fellowship (e.g., critical care, ultrasound, administration) that bridges ED and medicine services

2. If You Go Unmatched

If you go unmatched and still feel strongly about EM–IM or EM/IM-related careers, options include:

• Prelim IM year or transitional year

  • Use the time to:
    • Strengthen clinical evaluations
    • Build relationships and get powerful new letters
    • Demonstrate strong in-training exam performance
  • Reapply with a more mature, clinically grounded application.

• Research year (preferably at an institution with EM–IM or strong EM/IM departments)

  • Focus on projects directly related to EM or IM, especially:
    • Sepsis care, ED-ICU transitions, readmissions, ED crowding, hospital flow.
  • Secure mentors who can vouch for your work ethic and growth.

• Additional coursework or a master’s (MPH, MHA, etc.)

  • This can help but is least effective if not paired with strong clinical or research performance.
  • Best when clearly aligned with a systems-level EM–IM interest (e.g., ED–inpatient flow, healthcare quality).

In any of these paths:

• Use the time to prove that your low board scores are not the full story.
• Aim for high-quality letters and tangible achievements that overshadow old exam numbers.

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FAQs: EM–IM Combined and Low Step Scores

1. Is it realistic to match EM–IM combined with a low Step 1 score?

Yes, if:

• Step 2 CK is stronger or at least stable and passing on the first attempt.
• Your clinical performance in EM and IM is clearly above average.
• You have strong, specific letters from both EM and IM.
• Your personal statement and interviews communicate a convincing EM–IM narrative and a clear plan for success.

For applicants with a low Step 1 but solid Step 2 CK, EM–IM is challenging but realistic, especially if other parts of the application are strong.

2. I have low Step 2 CK as well. Do I still have a chance at EM–IM?

It’s more difficult but not impossible. Your odds improve if:

• Your EM and IM clerkship grades and comments are excellent.
• You have outstanding SLOEs/letters that explicitly counter concerns about knowledge and exam performance.
• You clearly demonstrate:
  • What went wrong in exam preparation
  • What you have concretely changed
  • Any early signs of improvement (e.g., subject exams, in-training exams)

You should still apply broadly to IM and EM programs and treat EM–IM as a reach, not your only plan.

3. As a DO applicant with COMLEX but no USMLE, how do low scores affect my EM–IM chances?

EM–IM programs vary:

• Some accept COMLEX alone and are familiar with its interpretation.
• Others strongly prefer or require USMLE scores.

If your COMLEX scores are low and you don’t have USMLE:

• Research program requirements carefully.
• Reach out (if appropriate) to confirm they consider COMLEX-only applicants.
• Ensure your application is exceptionally strong in clinical evaluations and EM/IM letters.

If you still have time, discuss with your advisors whether taking USMLE Step 2 (even later) might broaden your options, recognizing this is a high-stakes decision if you’re concerned about performance.

4. Should I address my low scores in my personal statement or only if asked?

If your scores are clearly low or you have a failure, it’s usually better to:

• Address them briefly and directly in your personal statement:
  • 3–5 concise sentences
  • Factual explanation, reflection, and evidence of growth
• Then be prepared with a longer, well-structured explanation for interviews.

Ignoring an obvious red flag can come across as avoidance. A transparent, mature explanation can actually build trust and demonstrate professional insight—qualities EM–IM programs value highly.

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Bottom line: Low Step 1 or below average board scores do not automatically close the door to emergency medicine internal medicine combined programs. They do, however, require a more intentional strategy—from honest self-assessment and targeted applications to exceptional letters, a clear EM–IM mission, and a compelling narrative of growth and resilience.