Advertisement

Empathy: From Attribute to Relationship

  • David Ian JeffreyEmail author
Chapter

Abstract

This chapter outlines the change in students’ perceptions of empathy as they gain clinical experience with patients. Initially, they talk about as empathy as a possession, something that they have. Later, they see empathy as something that they do, as a dynamic process which is embedded in a relationship and much affected by the context of the clinical consultation with the patient. They describe the process of empathising with a patient.

References

  1. Agosta, L. (2014). A rumor of empathy: Reconstructing Heidegger’s contribution to empathy and empathic clinical practice. Medicine, Health Care and Philosophy, 17, 281–292.CrossRefGoogle Scholar
  2. Balint, M. (1957). The Doctor His Patient and the Illness. London: Tavistock Publications.Google Scholar
  3. Ballatt, J., & Campling, P. (2011). Intelligent Kindness. London: RCPsych Publications.Google Scholar
  4. Baron-Cohen, S. (2011). Zero Degrees of Empathy. London: Allen Lane.Google Scholar
  5. Barrett-Lennard, G. T. (1981). The empathy cycle: Refinement of a nuclear concept. Journal of Counseling Psychology, 28, 91–100.CrossRefGoogle Scholar
  6. Batson, C. (2011). These things called empathy: Eight related but distinct phenomena. In J. Decety & W. Ickes (Eds.), The Social Neuroscience of Empathy. Cambridge: MIT Press.Google Scholar
  7. Batson, C. D., & Shaw, L. L. (1991). Evidence for altruism: Toward a pluralism of prosocial motives. Psychological Inquiry, 2, 107–122.CrossRefGoogle Scholar
  8. Batson, C. D., Early, S., & Salvarani, G. (1997). Perspective taking: Imagining how another feels versus imaging how you would feel. Personality and Social Psychology Bulletin, 23, 751–758.CrossRefGoogle Scholar
  9. Batson, C. D., Batson, J. G., Slingsby, J., Harrell, K. L., Peekna, H. M., & Todd, R. M. (1991). Empathic joy and the empathy-altruism hypothesis. Journal of Personality and Social Psychology, 61, 413–426.CrossRefGoogle Scholar
  10. Bayne, H., Neukrug, E., Hays, D., & Britton, B. (2013). A comprehensive model for optimizing empathy in person-centered care. Patient Education and Counseling, 93, 209–215.PubMedCrossRefGoogle Scholar
  11. Bloom, P. (2016). Against Empathy: The Case for Rational Compassion. London: The Bodley Head.Google Scholar
  12. Bondi, L. (2003). Empathy and identification: Conceptual resources for feminist fieldwork. ACME: An International E-Journal for Critical Geographies, 2, 64–76.Google Scholar
  13. Bondi, L. (2014). Understanding feelings: Engaging with unconscious communication and embodied knowledge. Emotion, Space and Society, 10, 44–54.CrossRefGoogle Scholar
  14. Broyard, A. (1992). Intoxicated by My Illness: And Other Writings on Life and Death. New York: Fawcett Columbine.Google Scholar
  15. Buber, M. (1961). Between Man and Man. London: Collins.Google Scholar
  16. Buber, M. (2004). I and Thou. London: Continuum.Google Scholar
  17. Burks, D. J., & Kobus, A. M. (2012). The legacy of altruism in health care: The promotion of empathy, prosociality and humanism. Medical Education, 46, 317–325.CrossRefGoogle Scholar
  18. Campos, J. J., Walle, E. A., Dahl, A., & Main, A. (2011). Reconceptualizing emotion regulation. Emotion Review, 3, 26–35.CrossRefGoogle Scholar
  19. Chochinov, H. (2007). Dignity and the essence of medicine: The A, B, C, and D of dignity conserving care. British Medical Journal, 335, 184–187.PubMedCrossRefGoogle Scholar
  20. Cooper, B. (2011). Empathy in Education: Engagement, Values and Achievement. London: Bloomsbury Publishing.Google Scholar
  21. Coplan, A., & Goldie, P. (Eds.). (2011). Empathy: Philosophical and Psychological Perspectives. Oxford: Oxford University Press.Google Scholar
  22. Coulehan, J. L., Platt, F. W., Egener, B., Frankel, R., Lin, C.-T., Lown, B., et al. (2001). “Let me see if I have this right…”: Words that help build empathy. Annals of Internal Medicine, 135, 221–227.PubMedCrossRefGoogle Scholar
  23. Coulter, A. (2002). Patients’ views of the good doctor. British Medical Journal, 325, 668–669.PubMedCrossRefGoogle Scholar
  24. Davis, C. M. (1990). What is empathy, and can empathy be taught? Physical Therapy, 70, 707–711.PubMedCrossRefGoogle Scholar
  25. Decety, J. (2011). Empathy: From Bench to Bedside. Cambridge: MIT Press.CrossRefGoogle Scholar
  26. Decety, J., Yang, C.-Y., & Cheng, Y. (2010). Physicians down-regulate their pain empathy response: An event-related brain potential study. Neuroimage, 50, 1676–1682.PubMedCrossRefGoogle Scholar
  27. del Canale, S., Louis, D., Maio, V., Wang, X., Rossi, G., Hojat, M., et al. (2012). The relationship between physician empathy and disease complications: An empirical study of primary care physicians and their diabetic patients in Parma, Italy. Academic Medicine, 87, 1243–1249.PubMedCrossRefGoogle Scholar
  28. Derksen, F., Bensing, J., & Lagro-Janssen, A. (2013). Effectiveness of empathy in general practice: A systematic review. British Journal General Practice, 63, 76–84.CrossRefGoogle Scholar
  29. di Blasi, Z., Harkness, E., Ernst, E., Georgiou, A., & Kleijnen, J. (2001). Influence of context effects on health outcomes: A systematic review. The Lancet, 357, 757–762.CrossRefGoogle Scholar
  30. Eikeland, H. L., Ornes, K., Finset, A., & Pedersen, R. (2014). The physician’s role and empathy—A qualitative study of third year medical students. BMC Medical Education, 14, 165–173.PubMedPubMedCentralCrossRefGoogle Scholar
  31. Evans, M. (2012). Feeling my way: Emotions and empathy in geographic research with fathers in Valparaíso, Chile. Area, 44, 503–509.CrossRefGoogle Scholar
  32. Fox, R., & Lief, H. (1963). Training for “detached concern”. In H. Lief (Ed.), The Psychological Basis of Medical Practice. New York: Harper Row.Google Scholar
  33. Frank, A. (2004). The Renewal of Generosity. Chicago: University of Chicago Press.CrossRefGoogle Scholar
  34. Gallagher, S. (2012). Empathy, simulation, and narrative. Science in Context, 25, 355–381.CrossRefGoogle Scholar
  35. Garden, R. (2009). Expanding clinical empathy: An activist perspective. Journal of General Internal Medicine, 24, 122–125.PubMedCrossRefGoogle Scholar
  36. General Medical Council. (2009). Tomorrow’s Doctors: Outcomes and Standards for Undergraduate Medical Education. London: General Medical Council.Google Scholar
  37. General Medical Council. (2013). Good Medical Practice. London: General Medical Council.Google Scholar
  38. General Medical Council. (2015). Outcomes for Graduates (Tomorrow’s Doctors). London: General Medical Council.Google Scholar
  39. Gerdes, K. (2011). Empathy, sympathy, and pity: 21st-century definitions and implications for practice and research. Journal of Social Service Research, 37, 230–241.CrossRefGoogle Scholar
  40. Gilligan, C. (1982). In a Different Voice: Psychological Theory and Womens’ Development. Cambridge: Harvard University Press.Google Scholar
  41. Gleichgerrcht, E., & Decety, J. (2013). Empathy in clinical practice: How individual dispositions, gender, and experience moderate empathic concern, burnout, and emotional distress in physicians. PLoS ONE [Online], 8. Available http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0061526&type=printable. Accessed January 29, 2018.
  42. Gleichgerrcht, E., & Decety, J. (2014). The relationship between different facets of empathy, pain perception and compassion fatigue among physicians. Frontiers in Behavioral Neuroscience, 8, 1–9.CrossRefGoogle Scholar
  43. Goleman, D. (1996). Emotional Intelligence: Why Can It Matter More Than IQ? London: Bloomsbury Publishing.Google Scholar
  44. Håkansson, J., & Montgomery, H. (2003). Empathy as an interpersonal phenomenon. Journal of Social and Personal Relationships, 20, 267–284.CrossRefGoogle Scholar
  45. Halpern, J. (2001). From Detached Concern to Empathy: Humanizing Medical Practice. Oxford: Oxford University Press.CrossRefGoogle Scholar
  46. Halpern, J. (2003). What is clinical empathy? Journal of General Internal Medicine, 18, 670–674.PubMedPubMedCentralCrossRefGoogle Scholar
  47. Halpern, J. (2012). Gathering the patient’s story and clinical empathy. The Permanente Journal, 16, 1.CrossRefGoogle Scholar
  48. Halpern, J. (2014). From idealized clinical empathy to empathic communication in medical care. Medicine, Health Care and Philosophy, 17, 301–311.CrossRefGoogle Scholar
  49. Hardy, C. (2017). Empathizing with patients: The role of interaction and narratives in providing better patient care. Medicine, Healthcare and Philosophy., 20, 237–248.CrossRefGoogle Scholar
  50. Hegazi, I., & Wilson, I. (2013). Maintaining empathy in medical school: It is possible. Medical Teacher, 35, 1002–1008.PubMedCrossRefGoogle Scholar
  51. Hilfiker, D. (2001). From the victim’s point of view. Journal of Medical Humanities, 22, 255–263.CrossRefGoogle Scholar
  52. Hoffman, M. (2000). Empathy and Moral Development: Implications for Caring and Justice. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  53. Hogan, R. (1973). Moral conduct and moral character: A psychological perspective. Psychological Bulletin, 79, 217.PubMedCrossRefGoogle Scholar
  54. Hojat, M. (2007). Empathy in Patient Care: Antecedents, Development, Measurement, and Outcomes. New York: Springer.Google Scholar
  55. Hojat, M. (2016). Empathy in Health Profession Education and Primary Care. New York: Springer.CrossRefGoogle Scholar
  56. Hojat, M., Louis, D. Z., Markham, F. W., Wender, R., Rabinowitz, C., & Gonnella, J. (2011). Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine, 86, 359–364.PubMedCrossRefGoogle Scholar
  57. Hojat, M., Mangione, S., Nasca, T. J., Rattner, S., Erdmann, J. B., Gonnella, J. S., et al. (2004). An empirical study of decline in empathy in medical school. Medical Education, 38, 934–941.PubMedCrossRefGoogle Scholar
  58. Hojat, M., Vergare, M. J., Maxwell, K., Brainard, G., Herrine, S. K., Isenberg, G. A., et al. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Academic Medicine, 84, 1182–1191.CrossRefGoogle Scholar
  59. Hollan, D. (2008). Being there: On the imaginative aspects of understanding others and being understood. Ethos, 36, 475–489.CrossRefGoogle Scholar
  60. Hooker, C. (2015). Understanding empathy: Why phenomenology and hermeneutics can help medical education and practice. Medicine, Health Care and Philosophy, 18, 541–552.CrossRefGoogle Scholar
  61. Howe, A., Smajdor, A., & Stöckl, A. (2012). Towards an understanding of resilience and its relevance to medical training. Medical Education, 46, 349–356.PubMedCrossRefGoogle Scholar
  62. Howick, J., & Rees, S. (2017). Overthrowing barriers to empathy in healthcare: Empathy in the age of the internet. Journal of the Royal Society of Medicine, 110, 1–6.CrossRefGoogle Scholar
  63. Howick, J., Bizzari, V., & Dambha-Miller, H. (2018a). Therapeutic empathy: What it is and what it isn’t. Journal of the Royal Society of Medicine, 111, 233–236.PubMedCrossRefGoogle Scholar
  64. Howick, J., Moscrop, A., Mebius, A., Fanshawe, T. R., Lewith, G., & Bishop, F. L., et al. (2018b). Effects of empathic and positive communication in healthcare consultations: A systematic review and meta-analysis. Journal of the Royal Society of Medicine. https://doi.org/10.1177/0141076818769477.PubMedPubMedCentralCrossRefGoogle Scholar
  65. Husserl, E. (1989). Ideas Pertaining to a Pure Phenomenology and to a Phenomenological Philosophy. Second Book: Studies in the Phenomenology of Constitution. Dordrecht: Kluwer Academic Publishers.CrossRefGoogle Scholar
  66. Irving, P., & Dickson, D. (2004). Empathy: Towards a conceptual framework for health professionals. International Journal of Health Care Quality Assurance, 17, 212–220.CrossRefGoogle Scholar
  67. Jackson, V., Mack, J., Matsuyama, R., Lakoma, M. D., Sullivan, A. M., Arnold, R., et al. (2008). A qualitative study of oncologists’ approaches to end-of-life care. Journal of Palliative Medicine, 11, 893–906.PubMedPubMedCentralCrossRefGoogle Scholar
  68. Jamison, L. (2014). The Empathy Exams. London: Granta.Google Scholar
  69. Jeffrey, D. (2016a). Clarifying empathy: The first step to more humane clinical care. British Journal of General Practice, 66, 101–102.Google Scholar
  70. Jeffrey, D. (2016b). A duty of kindness. Journal of the Royal Society of Medicine, 109, 261–263.PubMedCrossRefGoogle Scholar
  71. Jeffrey, D. (2016c). Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter? Journal Royal Society Medicine, 109, 446–452.CrossRefGoogle Scholar
  72. Kearney, M. K., Weininger, R. B., Vachon, M. L. S., Harrison, R. L., & Mount, B. M. (2009). Self-care of physicians caring for patients at the end of life “being connected….a key to survival”. JAMA, 301, 1155–1164.PubMedCrossRefGoogle Scholar
  73. Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J., & Riess, H. (2014). The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE, 9, e94207.PubMedPubMedCentralCrossRefGoogle Scholar
  74. Kelly, J. (2017). When I say…empathy. Medical Education, 51, 573–574.CrossRefGoogle Scholar
  75. Kim, S. S., Kaplowitz, S., & Johnston, M. V. (2004). The effects of physician empathy on patient satisfaction and compliance. Evaluation and the Health Professions, 27, 237–251.CrossRefGoogle Scholar
  76. Kupetz, M. (2014). Empathy displays as interactional achievements—Multimodal and sequential aspects. Journal of Pragmatics, 61, 4–34.CrossRefGoogle Scholar
  77. Larson, E., & Yao, X. (2005). Clinical empathy as emotional labor in the patient-physician relationship. JAMA, 293, 1100–1106.PubMedCrossRefGoogle Scholar
  78. Light, A., Gupta, T., Burrows, A., Nandakumar, M., Daniel, A., & Karthikeyan, S. (2018). Learning empathy: The medical student perspective. The Clinical Teacher. https://doi.org?101111/tct.12801. Accessed December 23, 2018.
  79. Lipps, T. (1903). Asthetik. Leipzig, Germany: Leopold Voss Verlag.Google Scholar
  80. Little, P., Everitt, H., Williamson, I., Warner, G., Moore, M., Gould, C., et al. (2001). Preferences of patients for patient centred approach to consultation in primary care: Observational study. British Medical Journal, 322, 1–7.CrossRefGoogle Scholar
  81. Macintyre, A. (1985). After Virtue. London: Duckworth.Google Scholar
  82. Macnaughton, J. (2009). The dangerous practice of empathy. Lancet, 373, 1940–1941.PubMedPubMedCentralCrossRefGoogle Scholar
  83. Maguire, P., Faulkner, A., Booth, K., Elliott, C., & Hillier, V. (1996). Helping cancer patients disclose their concerns. European Journal of Cancer, 32, 78–81.CrossRefGoogle Scholar
  84. Main, A., Walle, E. A., Kho, C., & Halpern, J. (2017). The interpersonal functions of empathy: A relational perspective. Emotion Review, 9, 358–366.CrossRefGoogle Scholar
  85. Marshall, G. R. E., & Hooker, C. (2016). Empathy and affect: What can empathied bodies do? Medical Humanities, 42, 128–134.PubMedCrossRefGoogle Scholar
  86. Maxwell, B. (2008). Professional Ethics Education: Studies in Compassionate Empathy. New York: Springer.CrossRefGoogle Scholar
  87. Mercer, S. W., & Reynolds, W. J. (2002). Empathy and quality of care. British Journal of General Practice, 52, S9–S12.PubMedGoogle Scholar
  88. Montgomery, K. (2006). How Doctors Think: Clinical Judgment and the Practice of Medicine. Oxford: Oxford University Press.Google Scholar
  89. Morse, J. M., Anderson, G., Bottorff, J. L., Yonge, O., O’brien, B., & Solberg, S., et al. (1992). Exploring empathy: A conceptual fit for nursing practice? Image: The Journal of Nursing Scholarship, 24, 273–280.Google Scholar
  90. Neumann, M., Scheffer, C., Tauschel, D., Lutz, G., Wirtz, M., & Edelhauser, F. (2012). Physician empathy: Definition, outcome-relevance and its measurement in patient care and medical education. GMS Zeitschrift fur medizinische Ausbildung, 29, 1–21.Google Scholar
  91. Neumann, M., Wirtz, M., Bollschweiler, E., Mercer, S., Warm, M., Wolf, J., et al. (2007). Determinants and patient-reported long-term outcomes of physician empathy in oncology: A structural equation modelling approach. Patient Education and Counseling, 69, 63–75.PubMedCrossRefGoogle Scholar
  92. Noddings, N. (1984). Caring: A Feminine Approach to Ethics and Moral Education. Berkeley: University of California Press.Google Scholar
  93. Noddings, N. (2013). Caring: A Relational Approach to Ethics and Moral Education. Berkeley: University of California Press.Google Scholar
  94. Nogueira-Martins, M. C. F., Nogueira-Martins, L. A., & Turato, E. R. (2006). Medical students’ perceptions of their learning about the doctor-patient relationship: A qualitative study. Medical Education, 40, 322–328.PubMedCrossRefGoogle Scholar
  95. Norfolk, T., Birdi, K., & Walsh, D. (2007). The role of empathy in establishing rapport in the consultation: A new model. Medical Education, 41, 690–697.PubMedCrossRefGoogle Scholar
  96. Pedersen, R. (2009). Empirical research on empathy in medicine—A critical review. Patient Education and Counseling, 76, 307–322.CrossRefGoogle Scholar
  97. Pedersen, R. (2010). Empathy development in medical education—A critical review. Medical Teacher, 32, 593–600.CrossRefGoogle Scholar
  98. Philips, A., & Taylor, B. (2009). On Kindness. London: Hamish Hamilton.Google Scholar
  99. Price, S., Mercer, S., & Macpherson, H. (2006). Practitioner empathy, patient enablement and health outcomes: A prospective study of acupuncture patients. Patient Education and Counseling, 63, 239–245.PubMedCrossRefGoogle Scholar
  100. Rakel, D. P., Hoeft, T. J., Barrett, B. P., Chewning, B. A., Craig, B. M., & Niu, M. (2009). Practitioner empathy and the duration of the common cold. Family Medicine, 41, 494–501.PubMedPubMedCentralGoogle Scholar
  101. Ratanawongsa, N., Teherani, A., & Hauer, K. E. (2005). Third-year medical students’ experiences with dying patients during the internal medicine clerkship: A qualitative study of the informal curriculum. Academic Medicine, 80, 641–647.PubMedPubMedCentralCrossRefGoogle Scholar
  102. Riess, H. (2015). The impact of clinical empathy on patients and clinicians: Understanding empathy’s side effects. AJOB Neuroscience, 6, 51–53.CrossRefGoogle Scholar
  103. Rogers, C. (1959). A theory of therapy, personality and interpersonal relationships as developed in the client-centered framework. In S. E. Koch (Ed.), Psychology: A Study of Science—Formulations of the Person and the Social Context. New York: McGraw-Hill.Google Scholar
  104. Rogers, C. R. (1961). On Becoming a Person. London: Constable.Google Scholar
  105. Roter, D. L., Hall, J. A., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998). Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical Care, 36, 1138–1161.PubMedCrossRefGoogle Scholar
  106. Schutz, A. (1967). The Phenomenology of the Social World. Evanston, IL: Northwestern University Press.Google Scholar
  107. Shapiro, J. (2008). Walking a mile in their patients’ shoes: Empathy and othering in medical students’ education. Philosophy, Ethics, and Humanities in Medicine, 3, 10–21.PubMedPubMedCentralCrossRefGoogle Scholar
  108. Slote, M. (2007). The Ethics of Care and Empathy. London: Routledge.CrossRefGoogle Scholar
  109. Smajdor, A., Stöckl, A., & Salter, C. (2011). The limits of empathy: Problems in medical education and practice. Journal of Medical Ethics, 37, 380–383.CrossRefGoogle Scholar
  110. Stein, E. (1989). On the Problem of Empathy (The Collected Works of Edith Stein Vol. 3). Washington, DC: ICS Publishers.Google Scholar
  111. Stepien, K. A., & Baernstein, A. (2006). Educating for empathy—A review. Journal of General Internal Medicine, 21, 524–530.PubMedPubMedCentralCrossRefGoogle Scholar
  112. Stocks, E. L., Lishner, D., & Decker, S. K. (2009). Altruism or psychological escape: Why does empathy promote prosocial behavior? European Journal of Social Psychology, 39, 649–665.CrossRefGoogle Scholar
  113. Stueber, K. (2006). Rediscovering Empathy: Agency, Folk Psychology and the Human Sciences. Cambridge: MIT Press.CrossRefGoogle Scholar
  114. Suchman, A. L., Markakis, K., Beckman, H. B., & Frankel, R. (1997). A model of empathic communication in the medical interview. JAMA, 277, 678–682.PubMedCrossRefGoogle Scholar
  115. Sulzer, S. H., Feinstein, N. W., & Wendland, C. L. (2016). Assessing empathy development in medical education: A systematic review. Medical Education, 50, 300–310.PubMedPubMedCentralCrossRefGoogle Scholar
  116. Svenaeus, F. (2014). Empathy as a necessary condition of phronesis: A line of thought for medical ethics. Medicine, Health Care and Philosophy, 17, 293–299.CrossRefGoogle Scholar
  117. Svenaeus, F. (2015). The relationship between empathy and sympathy in good health care. Medicine, Health Care and Philosophy, 18, 267–277.CrossRefGoogle Scholar
  118. Tavakol, S., Dennick, R., & Tavakol, M. (2012). Medical students’ understanding of empathy: A phenomenological study. Medical Education, 46, 306–316.CrossRefGoogle Scholar
  119. Tichner, E. (1909). Lectures on the Experimental Psychology of the Thought Processes. New York: Macmillan.CrossRefGoogle Scholar
  120. Vagle, M. D. (2016). Crafting Phenomenological Research. London: Routledge.CrossRefGoogle Scholar
  121. Von Dietze, E., & Orb, A. (2000). Compassionate care: A moral dimension of nursing. Nursing Inquiry, 7, 166–174.CrossRefGoogle Scholar
  122. Warmington, S. (2012). Practising engagement: Infusing communication with empathy and compassion in medical students’ clinical encounters. Health, 16, 327–342.PubMedCrossRefPubMedCentralGoogle Scholar
  123. Watson, J., & Greenburg, L. (2011). Empathic resonance: A neuroscience perspective. In J. E. Decety & W. Ickes (Eds.), The Social Neuroscience of Empathy. London: MIT Press.Google Scholar
  124. Wensing, M., Jung, H. P., Mainz, J., Olesen, F., & Grol, R. (1998). A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain. Social Science and Medicine, 47, 1573–1588.PubMedCrossRefPubMedCentralGoogle Scholar
  125. Wispé, L. (1986). The distinction between sympathy and empathy: To call forth a concept, a word is needed. Journal of Personality and Social Psychology, 50, 314.CrossRefGoogle Scholar
  126. Zaki, J., & Williams, W. C. (2013). Interpersonal emotion regulation. Emotion, 13, 803.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© The Author(s) 2019

Authors and Affiliations

  1. 1.University of EdinburghEdinburghUK

Personalised recommendations