Essential Strategies for Non-US Citizen IMGs with Low Step Scores in Surgery Residency

Preparing for a general surgery residency match as a non-US citizen IMG is demanding under any circumstances. Doing it with a low Step score or below average board scores adds another layer of complexity—but it is not automatically disqualifying. Many foreign national medical graduates have successfully matched into general surgery despite a low Step 1 score or Step 2 CK score by using deliberate, targeted strategies.

This article walks through practical, evidence-based approaches tailored specifically to you: a non-US citizen IMG aiming for a general surgery residency in the United States with less-than-ideal scores.

---

Understanding “Low Scores” in the Context of General Surgery

Before you build a strategy, you need clarity on where you stand and what “low” actually means in the surgery residency match.

1. What counts as a low Step score in surgery?

For general surgery, programs are often numbers-focused because of the specialty’s intensity. While the exact thresholds change year to year:

• Historically, Step 1:

  • A below average Step 1 (prior to pass/fail) was typically <230 for competitive surgery programs.
  • Now that Step 1 is pass/fail, programs look more heavily at Step 2 CK.

• Step 2 CK:

  • 250+ is highly competitive.
  • 240s are solid.
  • Scores in the 220s or below often place applicants in the “may not interview” or “screen-out risk” category for many mid to top-tier programs, especially for non-US citizen IMGs.

If you are a non-US citizen IMG with a Step 2 CK < 230 or a previous Step 1 < 220 (if still visible), you are typically in the matching with low scores category for general surgery.

2. Why low scores matter more for non-US citizen IMGs

Programs face several constraints that can disadvantage a foreign national medical graduate with lower numbers:

• Visa sponsorship requirements (H-1B or J-1)
• Limited budgeted positions for IMGs
• Institutional or GME-imposed score filters
• Large volume of applications, leading to automated cutoffs

This doesn’t mean you can’t match; it means your application must be more deliberately structured and strategically targeted than that of an average US grad.

3. Reframing your mindset

A low score is:

• A data point, not your full professional identity.
• A signal that you must:
  • Overcompensate in other domains (research, letters, hands-on US experience)
  • Be hyper-strategic in program selection
  • Communicate your narrative effectively

Your score is fixed now; your strategy is not. The rest of this article is about building that strategy.

---

Building a High-Impact Application Despite Low Scores

With suboptimal numbers, the rest of your application must be exceptional and coherent. Think of your file as a portfolio with several pillars.

1. Strengthen your US clinical and surgical exposure

For a non-US citizen IMG in general surgery, US clinical experience (USCE) is almost non-negotiable.

Aim for:

• Sub-internships / Acting internships (AI) in general surgery or surgical subspecialties

  • Set up at institutions that accept or historically match IMGs.
  • Perform at the level of an intern: pre-rounding, writing notes, presenting patients, staying late for cases.

• Hands-on electives (not just observerships)

  • Direct patient contact, order entry, note writing—these are far more valuable than shadowing.

• If hands-on is not possible, focused surgical observerships with:

  • Defined goals (OR exposure, morning conferences, M&M, tumor board).
  • Regular feedback from attendings.

Why this matters with low scores:

• Strong in-person performance can override some numerical concerns.
• Faculty who see your work ethic are more likely to advocate to the program director on your behalf.
• Excellent USCE is often more heavily weighted than a modest score difference among competitive applicants.

Actionable tips:

• Email surgery departments directly with a brief CV and a focused request for visiting rotations.
• Target programs known to be IMG-friendly and/or that have historically sponsored visas.
• During rotations, ask for mid-rotation feedback and actively improve based on it.

2. Secure powerful letters of recommendation (LoRs)

With a low Step score, your letters become even more critical.

Aim for at least:

• 3 letters from US general surgeons, ideally:
  • Faculty directly supervising you in the OR and on the wards
  • A division chief, program director, or well-known academic surgeon if possible

Ask for letters that highlight:

• Your technical aptitude (instrument handling, suturing, attention to detail)
• Work ethic and resilience (early arrival, staying late, ownership of patients)
• Teamwork and communication skills
• Specific examples:
  • “Handled a difficult family conversation professionally”
  • “Stayed late to assist in an urgent laparotomy without being asked”
  • “Self-directed learning on hepatic surgery before a complex case”

If your scores are discussed, they should be framed as:

• One limited metric that does not reflect your true capability or performance.
• Contextualized if there were extenuating circumstances (illness, family emergencies, language transition), but be careful not to sound like you’re making excuses.

How to get strong letters:

• Let faculty see you take responsibility, not just follow orders.
• Ask:
  “Dr. X, I’m applying in general surgery. Would you feel comfortable writing me a strong letter of recommendation?”
• Provide a CV, personal statement draft, and list of cases or projects you worked on with them.

3. Build a credible research profile in surgery

Research can significantly offset concerns about low scores, especially in academic-leaning programs.

Tiered strategy:

1. Short-term wins (6–9 months)

   • Case reports and case series from your rotations
   • Retrospective chart reviews with modest sample sizes
   • Quality improvement (QI) projects in surgical workflows

2. Longer-term (12–24 months)

   • Join a full-time research fellowship in general surgery or a surgical subspecialty.
   • Work under a PI with a history of publishing and supporting IMGs.
   • Target at least 3–5 PubMed-indexed publications, abstracts, or conference presentations.

Prioritize:

• Topics in general surgery: colorectal, trauma, acute care surgery, HPB, minimally invasive surgery.
• Being second or third author on multiple projects is often better than one first-author paper that never gets published.

Why this helps applicants with low scores:

• Demonstrates intellectual discipline and perseverance.
• Provides new, non-test-based evidence of your academic capability.
• Puts you in daily contact with attendings who can later call program directors directly on your behalf.

---

Strategically Managing and Framing Low Scores

You cannot erase a low Step 1 or Step 2 CK, but you can control the narrative around it.

1. If Step 1 was low but Step 2 CK is pending

Since Step 1 is now pass/fail, not all IMGs will have numeric Step 1 scores visible. If you do:

• A low Step 1 can often be neutralized by:
  • A strong Step 2 CK (ideally ≥240)
  • A noticeable upward trajectory compared to Step 1 practice tests

Action items:

• Treat Step 2 CK as your redemption exam.
• Use NBME and UWSA practice tests to document improvement.
• If English or test anxiety were issues,:
  • Do timed question blocks daily.
  • Practice reading long stems quickly.
  • Consider professional coaching if anxiety is severe.

2. If both Step 1 and Step 2 CK are below average

You will need to:

• Overweight everything else: USCE, research, LoRs, personal statement.
• Be realistic about the range of programs likely to interview you.

Consider:

• Strengthening your profile for 1–2 additional application cycles, if financially and personally feasible.
• Pursuing:
  • A 1–2 year surgery research fellowship in the US.
  • A non-ACGME surgical preliminary position that can later convert to categorical (high-risk but sometimes successful).
  • A transitional or preliminary year in another field (e.g., internal medicine) with the goal of reapplying to general surgery, though this path is difficult.

3. Addressing low scores in your personal statement

You do not need to open with your low score, but you should prepare to address it briefly and constructively, especially if there were clear extenuating circumstances.

Example framing:

“While my Step 2 CK score is not as strong as I would have hoped, it occurred during a period of [brief context, e.g., transitioning to a new language environment/adjusting to a different exam style]. Since then, I have demonstrated my clinical and academic capabilities through [concrete achievements: high performance in US surgical rotations, hands-on care of complex patients, and active involvement in surgical research].”

Avoid:

• Long explanations or excuses.
• Blaming the test itself.
• Emotional language that suggests bitterness or resentment.

4. Using OET/TOEFL and other indicators to your advantage

For non-US citizen IMGs, strong performance on:

• OET/TOEFL (if applicable)
• In-service exams during prelim or research years
• Institutional assessments

can reinforce that your low Step was not due to a lack of baseline aptitude or language capability (especially if those scores are high and recent).

---

Targeting the Right Programs as a Non-US Citizen IMG with Low Scores

One of the most powerful levers you control is where you apply. Many strong applicants fail to match simply because their program list is misaligned with reality.

1. Know your profile category

As a foreign national medical graduate with a low Step score, your realistic targets will likely be:

• Mid-to-lower-tier university programs with a published history of sponsoring visas and accepting IMGs.
• Community-based general surgery programs affiliated with university centers.
• Programs in less popular locations:
  • Rural or semi-rural areas
  • Smaller cities in the Midwest, South, or interior states

Top academic programs (e.g., large coastal university hospitals) may be aspirational but should not dominate your list.

2. Research each program’s IMG and visa history

For each potential program, investigate:

• Does the program explicitly state they sponsor J-1 and/or H-1B visas?
• How many residents per year are IMGs?
• Do they list current residents’ medical schools? Are any non-US citizen IMGs?
• Is there a minimum Step 2 CK score published?

Tools and tactics:

• Program websites (especially current residents’ profiles)
• FREIDA and other databases
• Reaching out to current or recent residents on LinkedIn or via email
• Asking your research or clinical mentors for internal knowledge of which programs are IMG-friendly

3. Constructing a realistic program list

With low scores, volume matters, but it should be targeted volume, not random.

A common distribution for a non-US citizen IMG with low scores might be:

• 10–20 programs: “reach” (mid-tier academic centers with some history of IMGs)
• 40–60 programs: realistic targets (community or hybrid programs with clear IMG representation and visa sponsorship)
• 10–20 programs: safety (high-IMG, lower-score-accepting, often in less popular locations)

This could put you at 60–90 total applications, depending on your budget.

Also consider:

• Including preliminary general surgery positions as a parallel track.
• Applying to a small number of related specialties (e.g., preliminary medicine) if your priority is entering the US system at all, then later transitioning—but be cautious, as this can dilute your surgical narrative.

4. Timing your application

For applicants with low scores, early and complete applications are crucial.

• Have all documents (LoRs, MSPE, transcripts, USMLE scores, personal statement) uploaded before ERAS opens for programs.
• Avoid late submission. Many programs use rolling review and fill interviews quickly.
• If you are still waiting on Step 2 CK, but Step 1 is already low, consider:
  • Delaying the application cycle to have a strong Step 2 CK ready.
  • Or applying to a smaller, hyper-targeted list if Step 2 CK will be available within the first month of interview season and you are confident of a significant score jump.

---

Interview and Post-Interview Strategy: Turning Chances into Offers

Once you have interviews, your low scores become less central; your performance and follow-up can now make the difference.

1. Master your narrative about scores and resilience

Be prepared for versions of:

• “Can you tell me about your Step 2 CK score?”
• “What challenges have you faced in your medical journey?”

Your goal is to:

1. Acknowledge the score factually.
2. Briefly contextualize it (if appropriate).
3. Pivot to strengths and growth.

Example answer structure:

“Yes, my Step 2 CK score is lower than I had aimed for. At that time, I was [brief, neutral context]. I realized I needed to adapt my study methods and improve my test-taking strategy. Since then, I have demonstrated my capabilities by [excelling in US surgery rotations, taking on high-responsibility roles, publishing research, receiving strong feedback from my attending surgeons]. This experience has taught me how to recognize my weaknesses early and systematically work to improve them—something I think is crucial in surgical training.”

Avoid sounding defensive, overly apologetic, or dismissive (“The exam doesn’t reflect anything”).

2. Demonstrate alignment with surgical culture

General surgery residencies look for applicants who:

• Work hard without complaint.
• Handle stress, hierarchy, and criticism constructively.
• Are team players who care about patient outcomes more than personal recognition.

On interview day, emphasize:

• Specific experiences in which you:
  • Took ownership of complex patients.
  • Stayed late to help in the OR or with floor work.
  • Helped cover for a colleague in difficulty.
• Examples of constructive response to feedback from attendings.

3. Use your IMG and non-US citizen background as a strength

Frame your background as:

• Evidence of adaptability (new country, new system, new language).
• Proof of resilience (navigating visa processes, distance from family, financial limitations).
• Source of unique perspective on global surgery, resource-limited settings, or cultural humility.

Program directors often value diversity in their team; articulate how your experience enriches the residency.

4. Post-interview communication

Being a foreign national medical graduate with low scores means every signal of genuine interest matters.

• Send thoughtful, specific thank-you emails within 24–48 hours.
• Reference:
  • Particular cases, conversations, or program features that resonated with you.
  • How you see yourself contributing to their team.
• If a program truly becomes your top choice, consider a clear, honest communication (following NRMP rules) expressing that they are your top choice. Do this sparingly and only if you mean it.

---

Frequently Asked Questions (FAQ)

1. Is it realistic for a non-US citizen IMG with low Step scores to match into categorical general surgery?

Yes, but it is challenging and often requires multiple reinforcing strengths:

• Strong US surgical rotations with outstanding letters.
• Meaningful research output in general surgery.
• Strategic program selection that heavily targets IMG-friendly and visa-sponsoring institutions.
• Possibly 1–2 years of additional research or clinical experience in the US.

Many applicants in this situation also apply to preliminary general surgery positions as a parallel pathway.

2. Should I retake Step 2 CK if my score is very low?

USMLE policies and timing constraints make retaking Step 2 CK rarely feasible unless there are exceptional circumstances (e.g., score invalidation). Most of the time, your better strategy is to:

• Maximize your performance in clinical rotations and research.
• Build a strong portfolio that demonstrates your true capability beyond the exam.
• Consider a long-term plan (research fellowships, prelim years) if immediate match seems unlikely.

3. Is it better to apply broadly now with low scores or wait a year to strengthen my CV?

If your current profile is:

• Low scores
• Minimal USCE
• No US-based research
• Weak or non-US-based letters

then waiting a year to:

• Complete 6–12 months of USCE
• Start or finish a research fellowship
• Obtain strong US letters

often substantially improves your chances compared with rushing an underpowered application.

On the other hand, if you already have:

• 2–3 solid US surgical rotations
• Emerging research involvement
• Reasonable funding and visa timing

you may reasonably apply now while continuing to strengthen your profile in case you need to reapply.

4. Should I consider other specialties if my Step scores are low?

It depends on your priorities:

• If surgery is your absolute passion and you are willing to:

  • Take extra years (research, prelim positions)
  • Manage financial and emotional costs
    then continuing to focus on general surgery is reasonable.

• If your primary goal is entering the US system and practicing clinically, you might:

  • Apply to less numerically competitive specialties simultaneously (e.g., internal medicine, family medicine), knowing that switching to surgery later is possible but difficult.
  • Discuss this with mentors who understand both your abilities and current match trends.

Be honest with yourself about your risk tolerance, financial situation, and long-term goals.

---

A low Step score is a serious obstacle for a non-US citizen IMG pursuing general surgery, but it is not an automatic barrier. By intentionally strengthening other parts of your application, targeting the right programs, and clearly telling your story of growth and resilience, you can still build a compelling candidacy for the surgery residency match.