Residency training represents a pivotal period in the development of physicians by bridging the gap between medical school and independent clinical practice. Since its establishment in the late 19th century under Sir William Osler, the residency model has undergone substantial reform, particularly in response to concerns regarding patient safety and trainee well-being.1,2 Historically, residents were subjected to grueling work hours, often exceeding 100 hours per week, with minimal supervision.3 The death of Libby Zion in 1984, widely attributed to resident fatigue and inadequate oversight, served as a critical turning point.4 This prompted the Accreditation Council for Graduate Medical Education (ACGME) to implement formal duty hour limits, supervision standards, and competency-based assessments. These reforms were intended to create a safer and more sustainable training environment for physicians in training.5 Since then we have also seen the FIRST and SECOND trials by the Surgical education Numbered Trials (SENT) group, and the Blue Ribbon Committee I and II to further evaluate ways to improve surgical resident education and limit problematic behaviors.6,7

Despite these changes, many aspects of the traditional residency culture persist, particularly those related to hierarchical structures and mistreatment.8 Emotional abuse, verbal harassment, and intimidation have been described as common experiences among trainees, especially in high-intensity specialties such as surgery. Exposure to such stressors contributes to alarming rates of burnout, depression, and suicide among residents. In response, organizations such as the ACGME and the American Medical Association (AMA) have developed antiharassment initiatives and implemented confidential reporting systems to address the mistreatment of trainees.9 While these efforts have improved the climate in many programs, concerns about toxic work environments remain, often described collectively using the term “malignant.”

Despite sweeping regulations and lesser degrees of occurrence, many of these strenuous and abusive behaviors and practices persist to this day and are commonly referred to as “malignant.” Malignancy is a feared characteristic of training programs amongst medical students before their clerkships and when looking for residencies to apply to. Some sites are perceived to have a bad reputation, and as a result, it is suggested that some medical students prefer not to match than to have a position at those programs. The perception of “malignancy” is also of importance to most residencies. Being labeled as malignant has the potential to affect not only the amount of applicants they receive but also the quality. Of the residences available to medical students, general surgery is frequently used as an example of malignancy given its association with long work hours and high acuity. Malignancy is also associated higher attrition rates, burnout, and harms diversification of the profession.10, 11, 12

The notion of a “malignant residency” has become increasingly salient among medical students preparing for the residency match process. Although the term lacks a formal definition, it is frequently used to characterize programs perceived as overly demanding, poorly supportive, or emotionally harmful. Programs with reputations for malignancy may struggle to attract applicants, and some students report preferring to go unmatched rather than train in such environments. General surgery, in particular, is frequently cited in student discourse as a specialty where malignant culture may be more prevalent due to long hours and intense clinical demands.

Despite the widespread use of this term, no qualitative research has systematically explored how medical trainees conceptualize malignancy in residency programs. This study seeks to address that gap by examining perceptions shared on the publicly available Reddit Residency Match Sheets—an annually updated, crowdsourced document that includes candid, anonymized commentary on residency programs from all levels. This was used given its diverse and anonymous opinions.13 Using qualitative thematic analysis, we aim to explore how medical students define and describe the characteristics of malignant general surgery residency programs. Our goal is not to validate or condemn specific programs, but rather to illuminate the lived experiences and perceptions of trainees navigating the match process, thereby contributing to ongoing efforts to improve the residency training environment.