Skip to Main Content

The Limits of Autonomy

May 01, 2022
by Mark David Siegel

As your acquaintance with clinical teachers grows, you will observe that although each of them has special knowledge and experience in some area of clinical medicine, they make no pretense of knowing it all.

-Paul Beeson

Hi everyone,

My internship began on the BMT Unit at the Hospital of the University of Pennsylvania. It was 1988, I was 25, and there were no residents on the floor. Seniors, fellows, and attendings were available if we needed them, but we were expected to figure things out on our own. My trusted advisor was a spiral “Washington Manual,” which taught me all I needed to know (or so I thought), from potassium repletion to anemia workups to defibrillator settings. The threshold for seeking help was high. The one time I remember calling a senior was for a patient with chest pain who’d developed “tombstones across the precordium,” which turned out to be an insignificant bundle branch block.

Back then, resident autonomy wasn’t the aspiration it is today. It was expected. Residents didn’t hold interns’ hands, and, on many services, we rarely saw attendings for more than an hour a day, when they came by to cosign our notes (i.e., “agree with above”). We weren’t entirely alone, but it was largely up to us to muddle through.

I arrived at Yale in 1992 fully self-sufficient, at least in my mind. One time, a patient was helicoptered in from Poughkeepsie with massive hemoptysis. Like any good pulmonary fellow, I spun her urine, found red cell casts, and told my attending, Dr. Matthay, we needed to start steroids. I don’t remember calling nephrology right away, but if I did it was probably out of courtesy.

It wasn’t until I became an attending that I discovered the limits of trainee autonomy. Too often, I’d walk into the MICU in the morning to find patients coding hours after they’d needed intubation. We spent much of rounds correcting antibiotic choices, blood gas interpretations, and ventilator settings. The residents were no less capable than I had been, and I winced, imagining the mistakes I must have made during training, assuming skills I didn’t have, oblivious to subtlety and nuance. I was the product of a training ethos that prized independence, where asking for help was deemed a sign of weakness. How many patients and trainees had suffered for lack of supervision?

The answer came in the form of a catastrophe when a smart resident failed to recognize pericardial tamponade in a patient with a perforated coronary artery. Throughout the night, the patient’s blood pressure had drifted down, and it never occurred to the resident (or the nurse) to call the attending. It wasn’t until the next morning when a fellow appeared and diagnosed the problem. But it was too late.

The event was a reckoning for the institution and my own thinking. We needed to dismantle all barriers to calling the attending. No more reluctance to waking faculty from sleep. No more praising residents for handling complex problems on their own. Instead, we’d recognize them for distinguishing sick from not sick, and for knowing when to call. We created laminated signs detailing situations where attendings should be notified immediately. These signs are still posted in some of our work rooms.

We will always promote resident autonomy, but let’s be clear about the autonomy we’re talking about: independent thought, developing diagnostic and treatment plans, leading rounds, and serving as the primary contact for patients and families. Our residency adheres to a philosophy of “graduated autonomy,” where independence builds over the course of three years. As medical educators, it’s our job to determine when residents are truly ready to function independently.

We’ve come a long way since I was a resident, and though it never should have been questioned, we now fully recognize the importance of supervision. In practice, this means looping in attendings immediately for all time-sensitive matters, including:

  • Deaths
  • Codes
  • Complications
  • Transfers to the Stepdown Unit or ICU
  • Refusals of admission to the SDU or ICU
  • Barriers to timely care, including delayed consults, procedures, and imaging studies
  • Disputes between teams
  • Code status changes
  • Any situation the attending should know about

There should be no obstacles to calling attendings, any time, day or night. I know I speak for all attendings when I say we can only leave the floors, or sleep at night, when we know we’ll be called promptly for any significant issue.

No one knows everything. I certainly don’t. There’s no end to what we can learn from others, particularly those with expertise and years of experience. This is true throughout our careers. Too often, we don’t know what we don’t know. For the sake of our patients and our trainees, we need to maintain the lowest threshold to call for help. It’s up to everyone to recognize the limits of autonomy.

Have a wonderful Sunday, everyone. It’s gorgeous outside, and I’m heading out for a long bike ride on the Farmington Canal.


Submitted by Mark David Siegel on May 01, 2022