Low Step 1 Score - IM Chances

[alligator3]

Hello all,
I know that there are hundreds to thousands of posts similar to this on reddit and I am sure many of you are annoyed by these kinds of posts, so I apologize in advance. I am working on a list of programs currently and after meeting with an IM attending at my school (mid-tier school in the northeast), she recommended applying to 40-50 low/mid-tier programs. My end goal is to attend an academic institute, ideally in a mid-size/large city, and become a research-oriented cardiologist > hospitalist.

Here are my stats:
- Step 1: 208 (unfortunate circumstance occurred during dedicated which I will discuss in my supplemental application...)
- Step 2: 250
- M3 grades: a third of my grades were Pass, High Pass and Honors but unfortunately got a pass on IM
- 11 publications (6 of which are first-author) - most of these papers are in cardiology
- Lots of leadership, research and volunteer experience, and a member of Gold Humanism
- solid LoRs and personal statement

Do you think 40-50 mid-tier programs are suffice? Do you think it is worth applying to a few reach schools that use a "holistic" approach (no Step cut-off) or will my application fees be going down the shredder? I am aware that fellowship will be incredibly difficult to achieve and I am aware that it is extremely unlikely to attend a "Top 20" program but I honestly don't care... I just want to become a good physician.
My list has almost every mid-tier academic program across the US that does not have a Step 1 cutoff or has a cutoff lower than my score but do any of you have any recommendations on which programs to apply to? I'd rather attend an academic program because I want to continue research but do you think I need to add community programs too? Are there any reach schools that I should consider applying to? Thank you very much for all of your time and again I apologize for being neurotic and adding another post to the myriad of similar posts out there.

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[collegestud2013]

If you're a USMD and have no other red flags you should be able to to get into a mid-lower tier IM program with that Step 1 score. I would focus on lower-tier academic programs and solid academic-affiliated community programs. Top IM programs will be difficult with that Step 1 score though it will be more mixed now that a lot of applicants will just have pass-fail. Is your goal IM hospitalist or cardiology? If it's cardiology the fellowship match will likely still be competitive by the time you apply, but if you do well in residency still attainable. Be sure to apply to only to IM programs that have in-house cardiology fellowships as having an in-house fellowship can give some otherwise borderline applicants an advantage. Also, you may want to do an IM chief year as at most institutions doing a chief year leads to very strong changes (and in many cases a near guarantee) of matching to an in-house fellowship of your choice.