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Trevor Gore examines the behavioural science every independent prescriber needs…

Independent prescribing has reignited an old debate, and much of the discussion has centred on whether pharmacists should prescribe, with a vocal minority of critics describing pharmacist prescribing as “dangerous quackery.”

These comments are not new, and every time pharmacy takes on a new role, similar concerns surface. Yet beneath the rhetoric lies a far more important question, “how do clinicians make safe diagnostic decisions?”

Before going any further, it is worth mentioning a behavioural science concept that is often misunderstood, the Dunning–Kruger effect, which describes how people with limited knowledge or experience may overestimate their competence because they lack the insight to recognise what they do not yet know.

Let me be clear, I do not believe this will be a defining problem for pharmacist independent prescribers. Pharmacists undergo rigorous education, structured prescribing training and are expected to prescribe only within their competence.

However, the Dunning–Kruger effect is a useful reminder that overconfidence is a human characteristic rather than a professional one. Every clinician, whether pharmacist, GP, nurse or consultant, is susceptible to cognitive biases that influence judgement. The debate should not be about which profession is “better” at diagnosing.

Instead, it should focus on how every clinician can make safer decisions, because diagnosis is not simply about knowledge, but recognising uncertainty, challenging assumptions and knowing when to seek more information or ask for help.

Every day, community pharmacists make diagnostic judgements. They decide whether a patient with a cough can self-manage or requires urgent referral, or whether a rash is likely to be self-limiting or needs medical attention.

They identify red flags, recommend treatment or advise patients to seek further care. Independent prescribing extends that responsibility by allowing appropriately trained pharmacists to move from recognising and assessing a condition to initiating treatment.

While the prescription is often the final step, the real clinical challenge is everything that happens beforehand. Diagnosis is fundamentally a decision-making process carried out under conditions of uncertainty.

Clinicians gather information, interpret evidence, weigh probabilities and decide what is most likely while remaining alert to what could be missed.

Knowledge is essential but alone is not enough. Our brains use mental shortcuts, or heuristics, to make decisions quickly, and usually these are remarkably effective, allowing experienced clinicians to recognise familiar patterns rapidly, but they can also introduce cognitive biases.

Anchoring bias places too much emphasis on the first impression, while confirmation bias encourages us to seek evidence supporting an initial diagnosis while overlooking conflicting information.

Availability bias gives undue weight to recent or memorable cases, and premature closure occurs when we stop considering alternatives because we have found a diagnosis that appears to fit.

These biases affect every healthcare professional because they are features of human thinking rather than professional failings. Interestingly, the opposite of the Dunning–Kruger effect is often seen in experienced clinicians.

The more they know, the more aware they become of uncertainty. They recognise that several diagnoses may fit the same presentation, ask more questions, seek additional evidence and are comfortable saying, "I'm not certain."

That is not weakness. It is clinical maturity, and perhaps the safest phrase any prescriber can use is, "I need to think about this."

For pharmacist prescribers, this means developing behavioural habits that reduce diagnostic error, and one of the simplest is deliberately slowing down before reaching a conclusion.

A brief mental pause to ask “what else could this be?" can prevent premature closure. Another useful strategy is deliberately looking for evidence that disproves the initial diagnosis rather than simply confirming it.

Safety-netting is a powerful tool because it reminds patients what to watch for, when to seek help and when to return, recognising that diagnosis is a process rather than a one-off decision.

Equally important is recognising the limits of one's competence. Independent prescribing does not remove professional boundaries but reinforces them, because safe prescribing includes knowing when to refer, when to seek advice and when another clinician is better placed to assess a patient.

As pharmacist prescribing becomes increasingly embedded within primary care, success should not be measured simply by the number of prescriptions written, but by the quality of clinical decisions, the willingness to recognise uncertainty and the ability to work collaboratively across the healthcare system.

We have already seen this with Pharmacy First, where initial scepticism has often softened once colleagues have seen the service working in practice, and confidence grows when people see value in action rather than theory.

The debate should therefore move beyond asking whether pharmacists diagnose, because they already make diagnostic judgements every day within their professional roles. The more useful question is “how do we help every clinician make better diagnostic decisions?”

Behavioural science provides part of the answer. By recognising cognitive biases, encouraging reflective practice, designing systems that reduce error and fostering the humility to acknowledge uncertainty, we create safer clinicians regardless of the letters after their name.

In healthcare, confidence may reassure patients, but humility protects them.

Trevor Gore is the founder of Maestro Consulting, a Self-Care Forum trustee and associate director at the Institute for Collaborative Working.