Prudence

You are a 3rd year medical student working a week of ED nights. This ED is in a hospital you've never been to, so you plug the address into your phone and follow the directions to get there. You initially think to spend some of the 20-minute drive in quiet reflection, but then you recall that the Shelf Exam is coming up, and you put on a review podcast at 2.5x speed.

It is a very busy night in the ED. You are asked to evaluate a patient who was in a car accident, and you dutifully apply the "ABCs of trauma". When this patient's chest X-ray comes back, you apply a different set of ABCs to read the chest X-ray. Another patient comes in complaining of chest pain, and you are quickly able to find an algorithm on UpToDate for "Evaluation of the adult with chest pain in the emergency department", which tells you the right workup to order before you even lay eyes on the patient. Later on, as you're writing your notes, one of the residents helpfully shares with you their note templates for different ED patient types.

Your attending calls you over. There’s a goals of care conversation happening in the ED, so he tells you to come and join in. The patient is an 87 year old man with DM2, HTN, HLD, COPD presenting after being found down this morning by his family with R sided weakness and aphasia, was found to have a L M1 occlusion with a L MCA territory ischemic infarct. He was walking at home with a walker but is oxygen dependent due to his COPD. You hear the stroke neurologist say, “it’s too late for tPA, but based on his perfusion imaging but it’s really borderline, we could take him for thrombectomy. He likely will have some swelling, and there’s a chance if we do or don’t do that that he may require a craniotomy. Or we could make him comfort measures. It’s really up to you.”

When things calm down a bit, you check your email and see an announcement that the 75 student interest groups at your institution have opened their leadership applications. You wonder how people find the time to dedicate to these groups and recall with some anxiety that you still don't even know what specialty you're applying into. Fortunately, you're able to find several Reddit threads where people have posted flowcharts for how to choose the right specialty for you. 

Discussion Questions

1. What are the excessive practices or characteristic vices that are opposed to this virtue and where do they appear in this case?
2. Does imprudence in small decisions have an effect on the chooser? What effect?
3. Does protocol make people more or less prudent? Can it be a tool? Can it be misused? How?
4. What roles do focus and contemplation play in becoming a prudent person and physician?
5. What is required to make a decision? How does autonomy versus paternalism play a role in the exercise of prudence?
6. When does caution about medical decision making become cowardice or indecision? Is it hubristic to make weighty medical decisions?
7. How is self reflection and personal growth a part of prudence?
8. List some concrete ways you can grow in prudence as a medical practitioner. List some concrete ways you can grow in prudence in your personal decisions.