I have been following SDN for >10 years now but this is my first post. I have been a resident at a top ten program in pediatrics. Baylor College of Medicine pediatrics. I think you hit the nail on the head.
I would consider carefully before choosing a large program but I do not have experience at another top 10 program. There was no autonomy, I repeat, no autonomy. Even if you do see rare patients,or high volume of patients, you would not manage them, you would write their note and answer nursing phone calls. There is an unspoken understanding of this and the several hundred nurses, ancillary staff, and attendings/fellows treat residents in similar manner and that is as note writers and phone answering persons. A small example among many, many others should suffice: when level I trauma comes in, or a generally sicker patient (most level 1 &2 go to Memorial Hermann) the attending will immediately grab a visiting adult ER resident and a fellow. It speaks volumes that the attendings do not strive to, enjoy, or feel compelled to involve their own pediatric residents in learning situations. This example was repeated many times on every rotation throughout the hospital every day. I was warned when I interviewed by residents and attributed that to their being tired, which is true, but I believe there was a general grumbling among a large portion of residents who agreed with me. There was no supervisory learning opportunities, no autonomy, with a well known demanding schedule including 8-9 months of q4 28 hour call. This program did not care about the residents, this was demonstrated on repeated attempts to provide face to face constructive feedback and or tailor my learning experience which was followed by rebuffs from program leadership and direct reprimands by attendings / department and overall overtly negative reactions from staff /attendings .The program had become a training program on fellowship support. I am certain, as I have been a part of a smaller to medium sized program, that you can get as good and better training at a residency program with less hours worked. I am not sure what the program once was but I believe it has changed.