van Rijssen et al. BMC Public Health 2010, 10:666 http://www.biomedcentral.com/1471-2458/10/666 that do interfere with medical decision-making.” Further- more, not every claimant will fit into a classification, or match a stereotype, and many complex claimants are “nondescript figures” (i.e. average, unnoticed people with very few pronounced stereotypes). Thirdly, an important disadvantage of stereotyping is that claimants are dynamic, and therefore physicians have to constantly make adjustments during the inter- view. Classification in stereotypes is stable, whereas the reality of an interview is an ever-changing dynamic pro- cess, and thus, as this physician concisely formulated: “Interviews from the past don’t give guarantees for the future.” (female, 61 years old, social insurance physician for 15 years) Moreover, the classification of a claimant might vary considerably during an assessment interview, for exam- ple depending on the phase of the interview (i.e. the claimant can be co-operative in giving information, but not co-operative when informed about decisions). Therefore, stereotypes have to be adjusted continuously. Minimising undesirable influences of stereotypes The physicians agreed that stereotypes are often unpro- ductive or undesirable, and therefore the negative influ- ence of stereotyping should be minimised. They used several strategies to achieve this aim: (1) being aware of counter transference; (2) making very formal assess- ments; (3) staying neutral to the best of their ability; and (4) being compassionate. Firstly, being aware of counter transference means that the physician is aware of his or her biases and pre- judices with regard to claimants: “That gives rise to a particular prejudice, which is okay, but you need to be aware of it”. During the assessment interview the physi- cians show this awareness by discussing findings and opinions with the claimant openly. This implies that “if you’ve trouble dealing with a particular type of patient, you should first take a look at yourself, because you’re the only one who knows what bothers you. Your per- sonality determines your allergies”. Outside the inter- view, discussing stereotypes with colleagues in discussion groups, supervision, or even psychotherapy is recommended: “We also confer with each other, we talk about things and hear from each other ... That also has to do with your own perception: your own attitude to life and what you expect.” (male, 42 years old, social insurance physician for 9 years) Many of the physicians argued that, when they know that they have a stereotype image of a claimant, they are Page 9 of 13 able to ‘un-stereotype’ just as easily as they stereotyped, although some said “but very often you just continue with your first impression”. When aware and unable to eliminate all influences, they might also consult other sources of information, for example medical specialists who are treating the claimant. Secondly, the assessment is made in a formal way, according to a structured assessment method, specifi- cally focusing on the information that is needed, or by applying a structured conversation/communication tech- nique. The physicians try to create a clear structure for the claimant, they are directive, they take their time to gather all the necessary information, they try to make contact in such a way that they obtain the most infor- mation from the claimant (e.g. “And there are different ways to treat people, depending on their abilities, their needs, what they don’t want, what they do want, their motivation, their intentions, and so on.”), and they adapt to the claimant’s intellectual level of conversation (e.g. using easier wording and language). They try not to become irritated, or to put pressure on themselves. When necessary, claimants are asked to write down their opinions and concerns in a letter that will be added to their file. Thirdly, the physicians stay neutral by telling them- selves to start with an unbiased, open-minded, objective attitude, and to be free-and-easy in the interview, also trying to avoid value judgements: “Then I have that all in mind and then I say to myself, no, go into the con- sulting room with a neutral, unbiased attitude.”. The physicians stated that they listen to claimants, take them seriously, and first follow their line of reasoning and let them tell their complete story before asking more in- depth questions. They try to readjust during the inter- view if they notice that the influence of a stereotype increases: “At first you’re neutral, but at a certain moment you adapt your interviewing technique to the person, to the person’s intellect, to the person’s reactions, because in the end your goal is to gather informa- tion within an hour. And with your techniques, you have to uncover that information. And depending on different groups you have to adapt.” (male, 44 years old, social insurance physician for 18 years) Fourthly, the physicians indicated that they are com- passionate. They openly discuss the claimant’s findings, opinions, and impressions with the claimant, and they mirror the claimant’s behaviour. One social insurance physician said that she acts in the opposite way to the claimant to elicit different behaviour (e.g. being very cheerful with a depressed claimant). Moreover, they also mentioned showing respect and sincere interest,