DO Graduate's Guide to Identifying Malignant General Surgery Residencies

Understanding “Malignant” Programs in General Surgery

For a DO graduate pursuing general surgery, finding the right residency is as important as matching at all. The term “malignant residency program” is commonly used by residents to describe an environment that is chronically toxic, unsafe, or exploitative. In these settings, serious problems go far beyond “tough but fair” training and into patterns of mistreatment, neglect, and poor education.

As a DO applicant navigating the osteopathic residency match (now unified under ERAS/NRMP), you may have additional concerns: Will a program truly value your osteopathic background? Will you get fair opportunities in a field that sometimes still skews MD-heavy? Identifying residency red flags early can save you years of frustration—or even outright harm.

This article focuses on how a DO graduate can identify malignant general surgery residency programs before ranking them, emphasizing:

• The difference between rigorous vs truly toxic training
• Practical toxic program signs specific to surgery
• How to research and detect residency red flags as a DO applicant
• How to ask questions on interview day that reveal program culture
• What to do if you suspect a program is malignant

Throughout, the examples center on general surgery, but the principles apply broadly to the surgery residency match.

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What “Malignant” Actually Means in Surgical Training

Malignant vs. Just Difficult

General surgery is demanding everywhere: long hours, high acuity patients, and intense responsibility. Not every exhausting program is malignant. A malignant residency program typically involves persistent, systemic issues such as:

• Chronic disrespect, bullying, or harassment
• Unsafe workloads with no attention to resident well-being
• Dishonesty in how cases, hours, or evaluations are handled
• Retaliation for speaking up
• Poor educational structure, leading to underprepared graduates

By contrast, a rigorous but healthy program may still have 80-hour weeks, frequent call, and high expectations—but combines this with:

• Respectful supervision
• Effective teaching and structured feedback
• Genuine interest in your development as a surgeon
• Transparent leadership and approachable program directors
• Reasonable flexibility during crises (illness, family emergencies)

Why DO Graduates Need to Be Especially Careful

As a DO graduate entering the surgery residency match, you face some unique concerns:

• Legacy bias in some older or highly traditional programs that still prefer MDs
• Less familiarity with osteopathic training among some academic faculty
• Unequal opportunities in research-heavy or “prestige-driven” settings if the culture is not genuinely inclusive

A program could be broadly benign but subtly problematic for DO residents specifically (glass ceilings, “MD-first” favoritism). Or, in a malignant environment, DO residents may be especially vulnerable to being sidelined, scapegoated, or given fewer opportunities.

When you evaluate programs, you therefore need to assess both:

1. Overall toxicity risks for all residents
2. Any DO-specific residency red flags that indicate limited support or inclusion

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Core Toxic Program Signs in General Surgery

Although every residency is different, malignant general surgery programs share recurring patterns. Learning to recognize these from the outside is critical.

1. Excessive Service Over Education

Surgical training requires substantial service: pre-rounding, notes, consults, call, and the rest. However, when service consistently crowds out learning, that’s a warning.

Red flags:

• Residents “live on the floor” doing scut with very limited OR time, especially as seniors
• Chiefs doing tasks that could be done by juniors, nurses, or PAs because there’s no staffing support
• Residents routinely missing conference, M&M, or didactics due to “patient care needs”
• No protected time for exam prep, ABSITE review, or skills lab

What this looks like in real life:

You ask, “How often do interns get into the OR?” A senior replies with a half-joke: “You’ll see the OR when your progress notes are done—so, not much your first year.” Everyone laughs uncomfortably. No one offers a reassuring clarification.

2. Disrespect, Bullying, and Public Humiliation

Surgical culture has evolved significantly, but malignant programs still normalize abuse.

Toxic behaviors include:

• Attendings or senior residents yelling, cursing, or throwing instruments in the OR
• Public humiliation during rounds or conferences, especially in front of nurses or medical students
• Sexist, racist, homophobic, or demeaning comments that go unchallenged
• Residents who appear visibly afraid to speak in front of certain attendings

Subtle warning signs:

• Faculty or residents say, “We believe in ‘pimping’ hard; if you can’t take the heat, you don’t belong in surgery,” with no mention of psychological safety or growth
• You hear comments like, “We had an intern cry every day last year” said with pride rather than concern

3. Chronic Duty Hour Violations and Safety Issues

General surgery can push close to duty hour limits in busy rotations—but malignant programs normalize systemic, unaddressed violations.

Major warning signs:

• Residents openly describe 100+ hour weeks as the norm, not the exception
• Pressure to under-report duty hours or “adjust” logs to avoid ACGME trouble
• Frequent post-call operating or operating when clearly too fatigued
• Residents covering multiple services alone overnight without attending backup

Why this matters:

This isn’t just about personal discomfort; it is a patient safety issue and a marker of poor systems-based practice. A program that tolerates unsafe fatigue is more likely to tolerate other forms of negligence.

4. High Attrition and Transfer Rates

In general surgery, some attrition is expected; a small number of residents discover they prefer another field. But when many residents leave—or try to—something is wrong.

Red flags:

• Multiple residents quit, are “counseled out,” or transfer over a 2–3 year window
• Residents talk about former colleagues in vague terms: “People move on,” without explanation
• A PGY-3 class of 2 when 4 matched originally, or noticeable gaps in the resident roster
• The program avoids straightforward answers about where departed residents went

For DO graduates specifically, pay attention to whether departing residents were DOs. A pattern of DO residents leaving while MDs stay can indicate biased treatment or lack of support.

5. Poor Case Volumes or “Stealing” Cases

To become a competent surgeon, you need both autonomy and adequate case numbers.

Malignant patterns:

• Residents repeatedly say, “Our numbers barely meet minimums,” especially seniors
• Mid-level providers, fellows, or attendings routinely take primary cases that should belong to residents
• Cases are “saved” for certain favorites (often MDs, legacy students, or research-track residents)
• DO residents consistently report getting fewer complex cases or being bumped from the OR

Ask specifically: “How are cases assigned among residents? How is fairness ensured?” Vague answers or clear hierarchies not based on training level or competence are problematic.

6. Weak Didactics and Exam Performance

The ABSITE (American Board of Surgery In-Training Exam) and eventual board certification are critical milestones. Malignant or severely disorganized programs often neglect structured teaching.

Residency red flags here:

• No consistent, protected weekly didactic for general surgery topics
• Residents study on their own with minimal institutional support
• ABSITE scores are “private” and never discussed; there’s no remediation plan for low performers
• Board pass rates are not shared, are well below national averages, or are excused with “Our residents are just not test-takers”

7. Leadership Instability and Lack of Transparency

General surgery requires strong leadership to coordinate services, cases, research, and education. Malignancy often starts or persists at the leadership level.

Warning signs:

• Frequent program director (PD) turnover or long periods with an “interim” PD
• Residents don’t know how decisions are made about rotations, case assignments, or remediation
• No clear grievance or reporting processes; or residents doubt their effectiveness
• Residents say things like, “We tell leadership problems, but nothing changes”

When you ask residents if they feel comfortable bringing concerns to the PD or chairman and the answer is a long pause or a careful “It depends”—take note.

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Unique Considerations for DO Graduates in General Surgery

The unified osteopathic residency match has greatly expanded opportunities for DO surgeons, but cultural lag exists in some surgery departments. You need to evaluate whether a program is:

1. Malignant in general, and
2. Specifically unwelcoming or limiting for DOs

1. DO Representation and Track Record

Ask directly or research through program websites and alumni lists:

• How many current residents are DOs? In which PGY years?
• Have DO graduates successfully gone on to competitive fellowships (MIS, vascular, surgical oncology, trauma/critical care)?
• Are any faculty members DOs—especially in leadership or core teaching roles?

Green flags:

• Multiple DO residents across classes
• Program discussing DO graduates’ fellowship matches or academic accomplishments with pride
• Faculty or leadership expressing familiarity with COMLEX and osteopathic training pathways

Red flags:

• “We’re open to DOs” but no DOs in the last several classes
• “You can take COMLEX only” but no clear understanding of how they interpret those scores
• Repeated “first DO” language used with surprise or hesitation

2. Subtle Bias and Microaggressions

Bias may appear in nuanced ways, especially in malignant or hierarchical cultures:

• Residents joking that DOs do “less real” medical school
• Attendings introducing MD residents as “future surgeons” and DOs as “rotating students”
• DO residents describing needing to outperform constantly just to be seen as equal
• Unequal distribution of “prestige” cases, research projects, or teaching roles

When you speak to DO residents (if present), ask how they’ve been treated and whether they feel they had to overcome skepticism.

3. Support for COMLEX and USMLE Pathways

Many DO graduates now take both COMLEX and USMLE, but not all. Gauge how comfortable the program is with interpreting your credentials.

Questions to clarify:

• “How do you evaluate COMLEX scores compared with USMLE?”
• “Have residents here taken only COMLEX? How has that affected them?”
• “Do you have any preference for how we handle future licensing exams and board prep?”

If answers are vague or dismissive, and there are no recent DO residents, the program may not be truly prepared to support a DO graduate in high-stakes assessments.

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How to Research and Detect Residency Red Flags Before Interview Day

You can identify many potential issues before you spend time and money interviewing.

1. Use Public Data Strategically

Check:

• ACGME / FREIDA / program websites
  • Resident roster: missing names or photos may indicate high turnover
  • Case numbers, board pass rates, attrition (if disclosed)
• ABS data and program reputation
  • Talk with your surgery chair or advisor—many know which programs are considered problematic

2. Read Between the Lines of Online Reviews

Websites like Reddit, SDN, and specialty forums contain both noise and useful signals. Approach them critically:

• Look for consistent patterns over several years, not one angry post
• Pay attention if multiple, independent sources call a program:
  • “Malignant”
  • “Brutal with no learning”
  • “Run by fear”
• Compare online chatter with what you hear from your home institution’s faculty and recent graduates

3. Network with Current and Recent Residents

Nothing replaces direct conversations:

• Use alumni networks from your DO school to identify graduates in general surgery
• Ask them privately about programs on your list:
  • “Have you worked with or heard about this program?”
  • “How do they treat DOs?”
  • “Would you rank it if you were applying again?”

People are usually honest in one-on-one conversations, especially when they understand you’re trying to avoid a bad fit.

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Interview Day: Questions and Tactics to Expose Toxicity

Interview days are highly curated, but carefully targeted questions can still reveal a malignant residency program.

1. Questions for Residents

Ask in small groups or one-on-one, ideally without faculty present:

• “How often do duty hours exceed 80 hours, and how is that handled?”
• “When someone is struggling academically or personally, what does the program actually do?”
• “Have residents left the program in the last few years? Why?”
• “Do you feel safe speaking up about concerns without retaliation?”
• “How are OR cases assigned among residents? Do you feel it’s fair?”
• “As a DO (or for DO colleagues), have you or they felt fully included and supported?”

Pay attention as much to body language and hesitations as to words. Residents who glance at each other nervously or give rehearsed, identical answers may be signaling that they’re not free to speak openly.

2. Questions for Leadership

You can ask program directors more formal questions that still highlight potential malignancy:

• “What changes have you made in the past 2–3 years based on resident feedback?”
• “How do you monitor for and address bullying or harassment?”
• “How do you ensure DO and MD residents have equal opportunities in the OR and for research?”
• “What are your expectations for resident wellness and time off?”
• “What’s your current board pass rate, and how do you support residents who struggle?”

Good leaders answer these directly and with examples. Malignant-prone programs may respond with defensiveness, vagueness, or misdirection.

3. Observe the Environment

During your visit, quietly observe:

• How residents and attendings speak to each other in hallways and workrooms
• Whether residents appear chronically exhausted, disengaged, or demoralized
• The mood in the OR board areas or conference rooms (tense vs collegial)
• Whether DO residents (if present) interact seamlessly or seem peripheral

Your gut reaction matters. If the atmosphere feels oppressive or joyless, don’t ignore that.

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Balancing Risk and Opportunity When Ranking Programs

After interviews, DO graduates in the general surgery residency match often feel pressure to rank every program that might take them. But ranking a clearly malignant program can have long-term consequences.

1. When a “Malignant” Option Might Still Be Too Risky

You may consider risking a tough environment for the sake of matching in general surgery. However, consider not ranking a program if:

• Multiple independent sources label it malignant
• Residents openly express regret about being there
• You see clear signs of abuse or chronic duty hour violations
• DO residents have conspicuously worse experiences than MD peers
• Attrition is high and leadership defensive about it

Not matching and pursuing a reapplication strategy, a preliminary year, or a different path may still be better than spending 5–7 years in an unsafe or abusive program.

2. Differentiating “Hard but Worth It” from Malignant

You might encounter programs that are brutally busy but clearly committed to training excellent surgeons. Positive signs even in a tough environment:

• Residents emphasize, “It’s hard, but leadership listens and improves things”
• Graduates consistently match into strong fellowships
• DO residents speak of being genuinely valued and respected
• Duty hours may be stretched, but there’s no pressure to falsify data, and changes are being made to fix chronic problems
• Teaching in the OR is strong, and senior residents clearly develop autonomy

These may still be appropriate options for a DO graduate pursuing high-caliber general surgery training.

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FAQs: Identifying Malignant General Surgery Programs as a DO Graduate

1. Are malignant programs more common in general surgery than other specialties?
Surgical training tends to be intense everywhere, and historically some programs normalized harsh behavior. While culture is improving, malignant programs still exist in general surgery. However, they’re not the norm. Many programs are rigorous but fundamentally supportive. Your job is to distinguish “tough but educational” from truly toxic.

2. As a DO, should I avoid all programs that have never matched a DO before?
Not necessarily. A program might simply not have had many DO applicants historically. However, absence of DOs combined with vague answers about COMLEX, no DO faculty, or subtle bias during interviews are concerning. If a program is otherwise strong and genuinely enthusiastic about you, being “the first DO” can be a positive step—just ensure that it doesn’t coexist with other residency red flags.

3. What if I discover a program is malignant after I’ve already ranked it highly?
If this realization occurs before the rank list deadline, adjust your list—don’t hesitate to move a malignant residency program lower or off your list entirely. If it’s after Match Day and you’ve matched there, focus on building support: connect with GME, identify mentors, use institutional wellness and ombudsman services, and document any serious mistreatment. In extreme cases, residents can seek transfers or report to oversight bodies, but these processes are complex and should be navigated with legal and professional guidance.

4. Is it better to match into a malignant general surgery program or not match at all as a DO?
This is highly individual and depends on your risk tolerance, financial situation, and alternative options (prelim year, research, reapplication, or a different specialty). Still, many residents who have been through malignant environments would argue that years of mistreatment, burnout, and poor training are not worth it, even for the dream of being a surgeon. Discuss your specific situation with trusted mentors who understand both general surgery and the osteopathic residency match landscape.

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Being strategic and skeptical—especially as a DO graduate—can help you avoid malignant general surgery programs while still pursuing the training you want. Seek information early, ask honest questions, and trust both the data and your instincts. A program that respects you as a DO today is far more likely to train you into the surgeon you want to be tomorrow.