Table 2 The domain of social influences

Patients’ trust supports GPs’ medication authority (GP, CP, CS)

13

GP20F: If there is trust, the people first consult their GP. Or they consult him again after visiting the specialist – well, I experience this happens more often in the rural area, because you have become a person of trust (…) Sometimes they even ask: ´the cardiologist has prescribed this, am I really supposed to take it?` Then they come to us and we discuss it.

14

GP24F: In my experience, many colleagues from other specialties add some things to the (medication) list (…) and then the patient reads the instruction leaflet and says: ‘I’ve received a prescription for this (by the specialist) but I would like you to check whether it is compatible with my other stuff.’

Pharmacists’ involvement may undermine GPs’ authority (GP, CP)

15

CP11F: Well, I feel uncomfortable here, because generally speaking, we are obliged to support the patient’s compliance. And when we have a prescription, we shouldn’t tell the patient: ´well this may not be quite appropriate`. So basically, we should support that this is what he is supposed to take, according to the doctor.

16

GP2F: When the patients get it that the pharmacist points out like: ‘What? Your GP prescribed cortisone? This is very harmful to you- are you sure you’re supposed to take this, or do you want to reconsider?’ Then, as a GP, you’re in a defense position.

In hierarchy with specialists, GPs come off as inferior (GP)

17

GP4M: I, as humble little GP, didn’t just decide: well, cardiology is recommending this, but I say I’ll deprescribe it. I mean, somehow it’s like David versus Goliath. That’s how you feel like, somehow. And then something happens and then it’s, ‘yeah, you little prick – why have you done that?’ Right?

18

GP9M: If you’re isolated from the world [at the country site], and have this unique feature, and it’s every Tom, Dick and Harry- That’s all very well, but then, whatever the ward physician is saying is much more relevant and important.

19

GP1M: The specialists are always the ones who know better. And the GP must do as the specialist says. But it does not have to be like that! (…) I could imagine that general medicine becomes the queen of medicine and in the end she is the one who decides. And then it’s just tough luck for the ear, nose and throat specialist because he has a lower position in the hierarchy. (…) Currently, the opposite is true.

20

GP3M: In the nursing homes, there’re many [psychiatrist] colleagues who look after the geriatric patients. And we totally stay out of this. I once deprescribed a medication at my own judgement (…) and this caused some major trouble. He [the psychiatrist] said, he was in charge and I should stay out of his therapy. So I stay out of it! [the other medications] -that’s my job. And he does the psychiatric medications.

Specialists exert pressure to continuing prescribing (GP)

21

GP8F: This problem occurs every time different specialty groups are concerned with one patient. Right? So, an orthopedist, a cardiologist, (…) a psychiatrist, and every physician prescribes what he would like to, or thinks to be necessary. And if you asked them right now, each one of them would say: ´Well, the Vitamin D and the calcium, he really needs both of these!`

22

GP6F: There’s a certain attitude we (GPs) need in front of the practitioners all around [when deprescribing]. Otherwise oneself is always the penny-pincher, the one who makes plans and talks a lot, and the one who’s responsible for it in case it’s not prescribed again.

23

GP6F: (about deprescribing a high-cost medication): No-one deprescribes it. Because nobody wants to be the one who did it (…) GP10M: But that’s what we have been discussing earlier: never change a running system!