When to prescribe what medication

The issue with prescribing a beta blocker is that it's one more medication to monitor. You have to watch their BP to make sure it doesn't drop. You also have to remember that beta-blockers do have long-term side effects (i.e. heart block), and they're not FDA-approved for managing asymptomatic tachycardia.

As for how to make a decision - it's complicated, and there are several factors involved.

As for why you might expect Vyvanse to be different from Adderall XR - lots of reasons. As an M2, I always used to think that you could predict what a drug would do based on its mechanism. As you get more experience, you realize that drugs often do things you don't expect because the body is way too complicated for us to be able to figure out exactly what things will do.

As for the actual differences between Vyvanse and Adderall XR - mostly pharmacokinetics. Also note that pharmacokinetics can vary from person to person, but Vyvanse generally has a shorter Tmax and half-life. The dosing availability is also somewhat different - for instance, 30mg of Vyvanse is equivalent to about 12-13mg of Adderall XR, which is not a dose that you can prescribe - so it could be that switching is helpful primarily because you're getting a stimulant dose that is more specifically appropriate for that patient.

As for what to do as an M2 - ask questions. A common misconception among med students is that we care how much you know (I thought this when I was a student). In reality, I'm more likely to give a high grade to a student who asks a lot of good questions and goes out of his/her way to learn independently (i.e. demonstrating an interest in learning/developing) than a student who knows a lot but doesn't ask questions (i.e. demonstrating an opinion that he/she already knows everything). From the attending's perspective, all students know practically nothing, so they probably won't notice the knowledge difference between an average student and a mildly above average student - if his knowledge is 100 units, an M2's knowledge ranges between 10-15 units, and it's hard to notice the difference between 10 and 15 when you're at 100. That said, I rarely come across a student who knows a lot AND asks a lot of questions, and those students get the highest grades... but they usually know a lot BECAUSE they ask a lot of questions, and their questions demonstrate their knowledge.

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When to prescribe what medication