Diagnostic decision making: the last refuge for general practitioners?

Nurses and pharmacists gained the right to prescribe as independent prescribers in the UK in 2007. Independent prescribers are responsible for the initial assessment of patients with diagnosed and undiagnosed conditions. Public policy discourse and the views expressed by health care professionals have conceptualised diagnostic decision making as being at a 'higher level' and more difficult than prescribing decision making. This paper presents five themes related to this premise. Firstly diagnostic decision making is put into the broader context of clinical reasoning which underpins all types of clinical decisions including both diagnostic and prescribing decisions. Secondly, the nature of diagnostic decision making is discussed as to whether it is indeed separable from the prescribing decision making process. Thirdly, the conception that all diagnostic decisions are inherently more difficult is contested when difficulty in decision making is more appropriately applied to all types of clinical decisions which involve greater complexity and uncertainty. The fourth topic concerns whether this perception of diagnoses as being more difficult is a response by the medical profession to the threat of independent prescribing, reflecting their wish to maintain professional power and dominance over other professions. The final section considers how expertise in diagnoses could be developed in nurse and pharmacist independent prescribers. To develop their expertise in making accurate diagnoses, medicine uses the model of learning basic science mechanisms followed by engagement with patient clinical problems followed by years of clinical experience. However this may be just one way of achieving diagnostic expertise. Other approaches, such as the use of deliberate practice and feedback, may be more suitable to the diverse range of knowledge and experiences of nurse and pharmacist prescribers.