Fellow vs Resident-run programs

resident autonomy is a very vague term. Whether there's a fellow or intesivist at night in the ICU or CCU doesn't automatically translate into being a fellow-run program. When I was a PGY3 and doing MICU nights, there was always a fellow and intesivist at night. The fellow is responsible for accepting patients to the ICU but he's not managing everything. We would intubate or do the lines and proceed with the plans. The intesivist is usually asleep and we would staff the patient when he wakes up. The fellow is there as a back up if somebody codes while you're doing a procedure in a different room or if 3-4 patients hit the unit at once and they all need procedures. But it was never like I had to go ask the fellow if I wanted to give somebody lasix or fluids or antibiotics or titrate pressors or sedation. I don't feel like this setup made me a lazy incompetent resident as some folks here think.

Patients in the ICU are often mismanaged not because of lack of knowledge but lack of experience. So I don't buy this "if there's supervision inhouse, you're going to ask them rather than thinking and reading and coming up with a plan". if you like to be micromanaged then you will find ways to ask people for help whether they're inhouse or not and the opposite is true. When there's a complicated ICU situation, it's not usually something that you can just pull up a paper from pubmed or an article on uptodate and figure out the solution from there. It's rather a situation where you need somebody who is a little more experienced than a PGY-2 or PGY-3 to handle. That's OK guys. You're not the masterminds of critical care medicine yet. It's ok if you ask for help in cases like that. it doesn't make you a better resident if you come up with a plan on your own and it turns up to be a disaster. The patient's family are not going to appreciate the fact that screwing up is part of your learning curve.

It's also different if you're at a community or a small academic hospital where you get the run of the mill septic shock or respiratory failure or GI bleeds that residents should feel comfortable managing, or at a tertiary referral hospital where you can get extremely complicated and sick patients either from the ER or flown from hospitals around town. Those sometimes can't wait 8 hours before somebody comes in in the morning to make sure the resident did everything right.

I think about this way: if a family member of mine is extremely sick and needs ICU care, I would be fine with a competent resident taking care of them but I would feel way more comfortable knowing that there are more experienced people available inhouse and supervising what he/she doing overnight.

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Fellow vs Resident-run programs