van Rijssen et al. BMC Public Health 2010, 10:666 http://www.biomedcentral.com/1471-2458/10/666 Page 7 of 13 Table 2 Categories of claimants reported by physicians which form the basis for stereotypes and their characteristics (Continued) Deceitful/unreliable Excessive and unnecessary information - Deliberately deceitful - Unreliable - Stubborn - Invent disabilities - Have a hidden agenda - Manipulate - Give contradictory and inconsistent information - Might also be “too nice” - Give an overload of information - Keep talking (physician does not get a chance to intervene) - Autonomous - Elaborate - Pay a lot of attention to relevant as well as irrelevant details - Immediately place all their points on the agenda - Keep changing the subject - Need structure - May exaggerate disability claim in order to justify it The physicians also mentioned characteristics that classify the physician-claimant relationship as lacking in respect and acceptance, combined with a dominating attitude that has considerable influence on the interview (the upper left quadrant in Figure 1). This group includes claimants who are inclined to provide excessive and unnecessary information ("And it is not exactly that they won’t co-operate, but you’ve lost control over the interview. And that makes the interviews longer than you’d intended”) or whose behaviour is hostile, deceitful and/or unreliable ("Right, that man had arms that were bigger than my whole body, so to speak, so I think if he had hit me ... He was so full of anger, facing me. I thought, be careful now”). The physicians reported that they deliberately adapt their communication style to the claimant’s style of beha- viour (and thus to their stereotype of the claimant, as sum- marised in the four quadrants of the typology). For example, in interviews with claimants with dominant com- munication behaviour and a lack of respect in the relation- ship, physicians take care not to end up in an inferior position, they are cautious in their decision-making (because information might be missing or is not correct), they ask more in-depth questions, and they are more alert: “Then you start questioning them more, about their routine and their daily activities, for example, which reflects their capacity. To check whether their func- tional complaints match the things they tell me. That’s how I try to find out.” (male, 51 years old, social insurance physician for 9 years) Origins of stereotypes Most physicians reported that they were retrospectively aware that they unconsciously classify claimants in general groups. They saw this process as a characterisation or arrangement in their heads, a frame of reference, resulting from prior experiences. Based on this frame of reference they adapt their behaviour. However, some physicians sta- ted that they never apply stereotypes: they reported that they behave and communicate in the same way with all claimants, that their first impressions do not influence the interview, and that their reactions are always a direct con- sequence of what happens in the interview: “Actually, I start the interview in the same way with every person”. Nevertheless, focus group discussions revealed that all physicians do make classifications on the first encounter, further on during the interview, and also after the inter- view. Stereotyping after the interview occurs, in particular, when writing down the findings in the file, thinking back on the interview, and discussing the interview with collea- gues. Physicians deal with stereotypes both consciously (deliberately) and unconsciously. The physicians reported that the opinion about a clai- mant on the first encounter is based both on the infor- mation in the file and the first impressions when meeting the claimant in person. Physicians compare the information in the file with their memories of other, similar claimants, and then see a pattern: “Of course you create an image for yourself. For example, when I read that the interview will be with a 32 year-old tea- cher, I’ve already got a complete mental image, because I’ve already seen 500 of them”. In addition, the medical anamnesis and the reports written by other social insur- ance physicians who previously met the claimant often paint a clear picture: “I think there’s a difference between seeing a person for the first time and having a complete file with information from several social insur- ance physicians who have seen that person before”. Combining this information gives rise to expectations, opinions, feelings, and biases about the claimant.