van Rijssen et al. BMC Public Health 2010, 10:666 http://www.biomedcentral.com/1471-2458/10/666 comforting claimants, letting claimants know that they understand them, and taking a positive attitude. That is what it is all about: “Our profession actually has more to do with social contact. It’s not about being formal. We try to communicate in such a way that people feel at ease when they tell their story”. Discussion Main findings Qualitative analysis of the focus group meetings with the social insurance physicians showed that claimant beha- viour can be categorised into the following dimensions: ‘respect and acceptance in the physician-claimant rela- tionship’ and ‘the claimant’s influence on the interview’. Combined, these dimensions resulted in a communica- tion behaviour typology with eight octants with regard to the communication during assessment interviews. Physicians adapt their communication style to the clai- mant, depending on the location of the claimant’s beha- viour on both dimensions. Although stereotyping is usually an unconscious process, the physicians were aware that it was happening. They explained this as a frame of reference, resulting from prior experiences. Stereotypes mainly result from first impressions when reading the file and the first actual encounter. The phy- sicians were of the opinion that stereotyping has advan- tages and disadvantages. The main advantages were: it provides a framework for the assessment interview, it can save time, and it is fun to check whether the classi- fication is correct. However, they also thought that there are several important disadvantages: stereotypes often prove to be incorrect and expectations often remain unmet, a stereotype does not provide the physician with the complete picture, and because people are dynamic you constantly have to make adjustments. Therefore, to minimise the negative influence of stereotyping, physi- cians apply four strategies: being aware of counter trans- ference, making a very formal assessment, staying neutral to the best of their ability, and being compassionate. Findings in relation to other studies Our aim was to investigate whether, and if so, how stereotyping might influence medical disability assess- ments. Although the literature shows that objectivity in this respect is an illusion [10,11], some physicians stated that they are not influenced by stereotypes. Neverthe- less, their responses during the focus group meetings did indicate that they did apply stereotypes. Studies have convincingly shown that awareness of stereotypes and the motivation not to apply stereotypes is not enough to prevent their influence, but awareness and motivation are helpful [23]. Thus, teaching physicians who lack awareness - and therefore motivation - about Page 10 of 13 stereotypes is an important challenge for future inter- vention studies [23]. Findings reported in the literature, that stereotyping might influence the interpretation of symptoms and behaviour [7], are in line with our find- ings that symptoms and behaviour are characteristics according to which claimants are classified (i.e. clear physical diagnosis, mental or unclear diagnosis, respec- tively coping behaviour, behaviour during the interview). In general, the literature suggests that the motivation of claimants [5,9] is a relevant characteristic for physicians who make medical disability assessments, and their communication styles [7] did, indeed, seem to be affected by the stereotypes. Physicians indicated that they adjusted their communication to the behavioural style of the claimant, and this style seemed to be deter- mined by stereotyping, among other things. The results of our study replicated several general findings in medical disability assessment interviews: that physicians apply stereotypes and this increases their comprehension of patient behaviour [7,10], that physi- cians experience problems with stereotyping, and that they prefer individual information, and therefore try to minimise the influence of unproductive stereotypes [2]. With regard to the content of stereotypes, our results are also in line with reports in the literature. As men- tioned before, the results can be placed in the interper- sonal circumplex [20,21]. Moreover, the behaviour of the physicians towards the behaviour of the claimants is consistent with the predictions of the circumplex [24]: a respectful relationship initiated by the claimant evokes respectful behaviour from the physician; disrespectful behaviour evokes disrespectful behaviour, and a submis- sive claimant evokes an active, dominating response from the physician. However, a dominant claimant does not evoke a submissive response from the physician, which might be because physicians are extra alert with this type of claimant and take care not to end up in an inferior position. Moreover, Balsa and McGuire [25] showed that the patient’s degree of co-operation and the physician’s degree of effort both influence the physi- cian’s stereotyping with regard to patient behaviour. Our results concerning the dimension of mutual respect and acceptance, reflect this degree of co-operation, and our finding that whether or not claimants show a criti- cal, dominating attitude is important for physicians, reflects this degree of effort. Examples of both ‘auto- matic stereotyping’ and ‘goal-modified stereotyping’ [7] were found. It is known that stereotyping depends on the social context [10,14]. Our results did not support the impor- tance of general social characteristics, such as age and gender, in stereotyping by social insurance physicians, but the physicians did indicate that they consider the type of disability of the claimant (i.e. physical or