van Rijssen et al. BMC Public Health 2010, 10:666 http://www.biomedcentral.com/1471-2458/10/666 undesirable influence of stereotyping. Their strategies to avoid counter transference and to discuss prejudices about claimants with colleagues are useful in this respect [28,29], but paying explicit attention to being compassionate might also be important. These strategies could be taught in training courses or other educational settings for less experienced physicians, or to increase awareness of the potential influence of stereotyping in general. Since medical decisions, and thus also medical disability assessments, depend on clinical reasoning [30], awareness of the potential influence of stereotyping is important. Moreover, because it is known that a decrease in cognitive capacity can increase reliance on stereotypes and stereotype-confirming information [10], attention should be paid to the time limitations and information overload (and the fatigue that could result from this) that some social insurance physicians experience. One could argue that there is a tension between the process of observing claimants’ behaviour for determin- ing their work capacity and that of observing behaviour to form a stereotype. In determining work capacity, phy- sicians have to recognise a pattern, find evidence to con- firm this pattern, and thereby make a diagnosis [12]. Similarly, in stereotyping physicians recognise a pattern in claimant behaviour. The tension between these two processes comes from the notion that the first process of stereotyping is acceptable, but the last process is unwanted and only has disadvantages. However, this notion is not defensible because, firstly, the physicians in the focus group meetings indicated that they some- times use stereotypes as a diagnostic tool. Secondly, stereotypes are needed to comprehend others and also have other advantages (as our study showed). It is nevertheless important - because both diagnosing and stereotyping include generalisation - that physicians carefully check to what degree the pattern or stereotype matches the individual claimant and what specific addi- tional individual information is needed. Our results showed that social insurance physicians adjust their communication to the degree of respect in their relationship with the claimant. With respectful claimants, an instrumental communication style, paying little attention to the possible empathic, affective needs of claimants is usually sufficient, and therefore compas- sion is predominantly reserved for interviews with ‘criti- cal’ claimants. Because it is known from the literature that empathy influences the diagnosis, patient satisfac- tion, coping with bad news, and adherence to medical recommendations [31,32], this is an important finding that should be incorporated in future training courses. Training physicians to apply the interpersonal circum- plex to medical disability assessments might be benefi- cial in this respect. It is therefore important to address Page 12 of 13 the awareness and handling of stereotypes in education and training for social insurance physicians. Conclusions Physicians are partly aware of the influences stereotypes might have on their communication with claimants and on their decision-making. During assessment interviews, physicians adapt their communication style to the degree of respect and dominance in the claimant’s com- munication. This increases their comprehension of the way in which claimants communicate. Simultaneously, physicians often prefer to receive individual information, which is more accurate, and therefore try to minimise the negative influences of stereotyping on the interviews. Communication skills training or other training courses for physicians should focus on increasing awareness of the influences of stereotyping, by discussing stereotypes and prejudices. The most effective ways to minimise the undesirable influences of stereotyping should also be addressed. Additional material Additional file 1: Summary of the interview protocol Acknowledgements The authors thank R.M. van Veen, C. Ligthart and I. Wu for their assistance with the focus group meetings. They are also grateful to all the participating social insurance physicians for their contribution. This research project was funded by the Dutch ‘Stichting Instituut Gak’, a foundation that initialises and supports innovative projects in the Dutch welfare sector. Additional support was obtained from the Dutch Institute of Employee Benefit Schemes (UWV). Author details 1Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands. 2Research Center for Insurance Medicine, collaboration between AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands. Authors’ contributions HJvR and AJMS came up with the idea for the manuscript. HJvR wrote most of the manuscript and MB wrote some parts of the manuscript. AJMS, JRA and AJvdB revised and commented on the manuscript. All authors have read and approved the final version of the manuscript. Competing interests The authors declare that they have no competing interests. Received: 26 May 2010 Accepted: 3 November 2010 Published: 3 November 2010 References 1. Ames DR: Strategies for social inference: a similarity contingency model of projection and stereotyping in attribute prevalence estimates. 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