Qualitative insights into empathy in medical education: perspectives from students, doctors, and educators

Abstract

Background

Empathy is the cornerstone of high-quality medical education and clinical practice. It not only serves as a vital link for establishing trust-based doctor-patient relationships but also significantly impacts patients' treatment compliance and recovery outcomes. In medical education, an empathetic approach can cultivate future medical professionals' humanistic care awareness, enabling them to better understand patients' physical and mental sufferings.However, the understanding and cultivation of empathy vary remarkably across different cultural backgrounds.Thus, there is an urgent need to conduct in-depth research to clarify these issues and promote the better development of empathy-based medical education.

Methods

A total of 24 participants, including medical students, practicing doctors, and medical teachers, were recruited for this study. Semi-structured interviews were employed as the data-collection method. Each interview lasted approximately 30–60 min, and all interviews were audio-recorded and then transcribed verbatim.For data analysis, a three-level coding approach was adopted. The analysis was independently conducted by two members of the research team to ensure reliability and consistency.

Results

This study delves into empathy ability within medical education. The theme analysis yields significant results: the definition of empathy involves basic understanding with distinct emotional and cognitive emphases, multi-dimensional attributes showcasing empathy's roles in clinical scenarios, and the need for regulation due to its contradictoriness. Expression of empathy hinges on establishing doctor-patient trust and communication, with diverse expression ways and impacts on treatment and relationships. Influencing factors encompass educational background, clinical environment, and individual differences. Strategies for cultivation include teacher guidance, varied methods, and curriculum integration in the first classroom, and activity practice and values guidance in the second. These findings offer valuable insights and practical implications for enhancing empathy in medical education.

Conclusions

This study's core findings from cross-group analysis of medical students, doctors, and teachers show empathy in medical education is complex and multi-dimensional, involving emotional and cognitive empathy. Empathy abilities change dynamically during medical education, with students initially having high emotional empathy and later developing stronger cognitive empathy. Cultural differences in empathy, like between Western and traditional Chinese medicine, offer new perspectives. Practical implications include: designing curricula to cover both empathy types and adding cross-cultural content; using diverse teaching methods and optimizing clinical internships; organizing teacher training and improving teaching skills; establishing a comprehensive evaluation system with timely feedback. These insights and suggestions guide enhancing empathy in medical education.

Introduction

In the contemporary domain of medical education, the unceasing advancement of society has rendered the quality of the doctor—patient relationship a pivotal metric for gauging the efficacy of medical services. Empathy, without a doubt, stands as the core linchpin, exerting a profound influence on the outcomes of medical care. In the operational framework of the modern medical system, patients' expectations regarding medical treatment have undergone a profound transformation. Alongside the pursuit of effective disease cure, they have an escalating yearning to be comprehensively understood, respected, and tenderly cared for throughout the entire trajectory of diagnosis and treatment. This phenomenon further underscores the indispensable role of empathy within the medical scenario.

In recent years, an abundance of research outcomes has compellingly validated the significance of empathy in medical practice. For example, a large-scale investigation spanning multiple hospitals has revealed that when physicians possess a high degree of empathy, the incidence of patient complaints experiences a substantial decline, with an average reduction of around 40%. This finding robustly attests to the central efficacy of empathy in optimizing doctor-patient communication and effectively mitigating doctor-patient conflicts [1]. Moreover, other research has indicated that empathy can significantly improve patients' psychological states and enhance their confidence and ability to cope with diseases, thereby playing a positive role in promoting treatment outcomes [2].

In China, the "Action Plan for the Enhancement of Medical Humanistic Care (2024–2027)" jointly issued by four departments, including the National Health Commission, has elevated medical humanistic care, especially the cultivation of empathy, to an important strategic height. This plan emphasizes the comprehensive strengthening of emotional understanding and support for patients by medical staff in medical education and clinical practice. Through multi-dimensional measures such as improving the curriculum system, innovating teaching models, and optimizing clinical training, it aims to effectively enhance the empathy of medical students and medical staff. Consequently, this will comprehensively improve the doctor-patient relationship and enhance the overall quality and satisfaction of medical services [3].

Meanwhile, around the globe, there is an increasingly strong call from all sectors of society for the humanization of medical services. Advanced international medical education concepts are actively advocating for empathy-based education and continuously exploring practical cultivation paths and methods [4,5,6]. Although the critical importance of empathy in medical education is widely recognized, it still faces many challenges in practical educational settings. There is an urgent need for more in -depth and systematic research to find effective solutions.

The theory of empathy and its significance in medical education

Empathy, within the academic realm, is defined as the ability of an individual to keenly perceive and deeply understand the emotional states of others and, to a certain extent, experience them vicariously [7]. In the context of medical education, its significance is self-evident. This view is strongly supported by many cutting-edge international research findings.For example, through a large-scale multi-center study, Smith et al. [8] found that there is a strong positive correlation between the empathy demonstrated by doctors during clinical diagnosis and treatment and patients' treatment satisfaction, with a correlation coefficient as high as 0.75. This fully demonstrates that empathy can significantly enhance patients' recognition and acceptance of medical services. Furthermore, the long-term follow-up study by Johnson et al. [1] showed that the treatment compliance of patients under the care of doctors with a high level of empathy increased by approximately 35% compared to the control group. This powerfully proves the crucial role of empathy in promoting patients' active cooperation in treatment, thus having a positive impact on treatment outcomes.

From a theoretical framework perspective, empathy encompasses two important dimensions: cognitive empathy and emotional empathy [9]. Cognitive empathy mainly relies on an individual's knowledge reserve and thinking ability [10]. This enables doctors to rationally analyze the emotional roots of patients based on their professional knowledge. When dealing with patients suffering from complex chronic diseases, doctors use cognitive empathy to comprehensively consider factors such as the pathophysiological process of the disease, the potential psychological stress it may cause, and the social support system, thus comprehensively understanding the patients' emotional states.On the other hand, emotional empathy focuses on the deep emotional resonance between doctors and patients [11]. It prompts doctors to experience the pain and anxiety of patients as if they were in the patients' shoes. When facing the fear and helplessness of terminally-ill patients, emotional empathy allows doctors to provide more attentive and human-centered care and comfort to patients and their families.These two dimensions complement each other and jointly form a complete system of empathy ability, playing a crucial role in concert in medical education and clinical practice.

Research status and challenges of empathy in medical education

In recent years, research on empathy in medical education has achieved fruitful results globally. In terms of teaching strategies, a series of innovative methods have emerged continuously. Role—playing, as a commonly used teaching method, has been widely applied in medical education [12]. In the curriculum practices of internationally renowned medical schools such as Harvard Medical School, students play the roles of patients and doctors, deeply experiencing the emotions and psychological states of different roles, thus effectively enhancing their empathy awareness and communication skills [13]. Reflective writing has also become an important teaching tool. After completing clinical practice, students deeply analyze their emotional responses and behavioral performances during interactions with patients by writing reflective journals, thereby continuously improving their empathy abilities [14, 15]. In addition, simulated patient training, with the help of standardized patients or advanced virtual reality technology, creates highly realistic clinical scenarios for students, enabling them to accumulate rich experience in practice and strengthen their empathy abilities [16].

However, these studies still face many challenges during implementation. On the one hand, there are significant differences in the manifestations and cultivation models of empathy under different cultural backgrounds [17], but existing research has paid relatively little attention to this. In Western cultural backgrounds, where individual independence and autonomy are emphasized, the cultivation of empathy may focus more on personal emotional expression and self—awareness. In contrast, in East Asian cultures, influenced by collectivist values, the expression of empathy may be more implicit,and more attention is paid to the harmony of interpersonal relationships and the maintenance of the overall atmosphere. On the other hand, although a variety of teaching strategies have been proposed, their applicability and effectiveness in different educational contexts still need to be further verified [18].

Aims and research questions

In light of the above research status and existing problems, this study aims to deeply explore the understanding and practice models of empathy among medical students, practitioners, and educators in the context of Chinese medical education. The specific research questions are as follows:

• 1. In the Chinese medical education environment, how do different groups (medical students, doctors, educators) define and understand empathy? What are the similarities and differences between their cognitions and the common international views?

• 2. In China, how do educational background, clinical environment, and sociocultural factors influence the development of medical students' empathy ability?

• 3. Which teaching methods and strategies can effectively enhance the empathy ability of medical students?

Through the systematic study of these questions, this study expects to enrich the existing research on empathy in medical education, especially its manifestations in the Chinese cultural context. It aims to provide targeted and operable theoretical support and practical guidance for the cultivation of empathy ability in medical education, thereby promoting the in-depth development of medical education in the emotional dimension and enhancing the overall quality of medical services.

Methods

Research design

This study employed a qualitative research approach and utilized semi—structured interviews to collect the understandings and experiences of medical students, practicing doctors, and medical teachers regarding empathy. Qualitative research methods are suitable for exploring complex social phenomena such as the manifestations and impacts of empathy in medical education [19]. Through in—depth interviews, we were able to obtain detailed descriptions of empathy from the participants, thereby gaining a profound understanding of its application in different contexts and the challenges it faces.

Interviewers and reflection

The interviews were conducted by Fan Yang and Fuhao Lei. Both interviewers have research, learning, and practical experiences in the field of medical education and have received training in professional interviewing techniques, which ensures the effective implementation of the interviews.During the interview process, the interviewers maintained a neutral and objective attitude at all times. Meanwhile, they actively reflected on the impact of their own roles and behaviors on the interviews [20]. For instance, when faced with some relatively sensitive topics, the interviewers would reflect on whether their questioning methods were appropriate and whether they might lead participants to have a specific response tendency. They would then promptly adjust the interview strategies to ensure the acquisition of truthful and objective information.

Achievement of data saturation

During the data-collection process, we continued to conduct interviews until the state of data saturation was reached. We determined that data saturation was achieved when new interview data no longer generated new themes or concepts and provided extremely limited supplementation to existing themes and concepts [21]. In actual operation, as the interviews progressed, we immediately analyzed the content of each interview and compared the themes and concepts in the new interview data with those in the already—collected data. For example, in the interviews with the student group, after interviewing 9 participants, we found that the information obtained from the subsequent 3 consecutive interviews only enriched and refined the existing themes, such as "educational factors influencing empathy ability" and "manifestation forms of empathy in the clinical environment", and no new core themes emerged. After discussion and evaluation by the research team, we believed that data saturation had been reached at this point, and we stopped the data-collection work. This ensured that we could fully obtain effective information while avoiding unnecessary waste of resources and consumption of time.

Participants

A total of 24 participants were recruited for this study, belonging to three groups: medical students, practicing physicians, and medical educators. The participants came from diverse medical backgrounds, covering different medical specialties, institutions, and working environments, ensuring the diversity and wide applicability of the research findings.All participants adhered to the principle of voluntary participation. Prior to their involvement in the interviews, we provided them with a detailed explanation of the research objectives and potential impacts [22]. Basic information of the participants, such as age, gender, professional background, and years of experience, was recorded during data collection and anonymized during subsequent analysis.

Data collection

The data for this study were amassed via semi—structured interviews, each of which endured for approximately 30 to 60 min. The interview protocol was meticulously designed to encompass inquiries regarding multiple pivotal dimensions. These dimensions included the definition and elucidation of empathy within the realms of medical education and professional trajectories; the modes of manifestation of empathy in both clinical and academic environments; the educational and environmental determinants that impinge upon the development of empathy capabilities; and, finally, the specific pedagogical approaches and strategies employed to enhance empathy. The Additional file 1 shows more detail. To guarantee the comprehensiveness and precision of the data, every interview was audio-taped. Post-interview, the recordings were transcribed verbatim, thereby capturing every nuance of the conversations and facilitating subsequent in—depth analysis.

Data analysis

The data analysis in this study was conducted using a three—level coding approach to gradually distill themes and patterns related to empathy. Initially, open coding was carried out, which involved making preliminary concept—based notations on the interview transcripts. Subsequently, axial coding was performed, during which related concepts were grouped into distinct categories. Finally, selective coding was employed to identify the core themes and categories.

The data analysis was independently executed by two members of the research team, thereby enhancing the reliability and consistency of the analysis. During the analytical process, our focus was primarily on the disparities in the understanding and manifestation of empathy among different groups. In conjunction with the specific experiences and backgrounds of the participants, we probed into the potential influencing factors. By comparing the perspectives of different groups, we were able to uncover the complexity and diversity that empathy confronts within the context of medical education.

Ethical considerations

This study strictly follows the Helsinki Declaration to ensure the standardization and scientificity of the research process [23]. Before starting the research, we actively submitted a detailed ethical review application to the Human Subjects Protection Committee of East China Normal University, comprehensively expounding the purpose, methods, potential risks, and protection measures for participants' rights and interests of the research. After strict evaluation and deliberation by the Human Subjects Protection Committee of East China Normal University, we successfully obtained ethical review approval (approval number:HR 385–2024).

Results

Basic information of participants

In terms of demographic characteristics, we collected information such as the gender, age, educational attainment, and years of work (for medical teachers and clinical doctors) of the research subjects. This was done to fully consider the potential impacts of these factors on the research results during data analysis. Specifically, there were 11 male participants and 13 female participants. Regarding the age distribution, 13 participants were aged 20–29, 6 were aged 30–39, 4 were aged 40–49, and 1 was aged 50–59. Among the participants, 14 had a bachelor's degree, 5 had a master's degree, and 5 had a doctor's degree. In terms of identity, there were 12 practicing doctors and teachers, and 12 medical students (see Table 1).

Table 1 Demographic characteristics of study participants

Coding results

Through a rigorous coding process, we distilled the following four themes, each of which encompasses several sub-themes. These findings provide rich and valuable information for a profound understanding of empathy in medical education (see Table 2).

Table 2 Theme analysis of empathy ability in medical education

Definition of empathy in medical education

Most participants agreed that empathy primarily lies in the power of "putting oneself in others' shoes," which enables one to perceive patients' emotions and establish emotional connections. For instance, a medical student stated: "Empathy means being able to consider things from the patient's perspective, and then being able to communicate with them more patiently to understand their feelings. The most important thing is actually considering the patient's own feelings." (S07) This emotional investment is regarded as the cornerstone of a good doctor-patient relationship. However, doctors and teachers emphasized that empathy goes beyond emotions and also encompasses cognitive processes. A doctor pointed out: "Sometimes, when we empathize, if necessary, we may take some actions and do something for the other party due to empathy." (D01) This indicates that empathy needs to maintain a balance between emotional resonance and professional judgment. Medical teachers further emphasized the leading role of empathy in medical education, believing that empathy is not only a quality that medical students need to cultivate but also a quality that teachers themselves should possess in order to better guide students. A medical teacher said: "In our current education, the concept of empathy actually focuses more on enabling students to understand and experience the inner world, emotions, and thoughts of others. Especially in the medical field, as a medical worker, only in this way can you help patients and establish trust with them, and then you can have effective communication. Its significance in the medical field, I think, is very important." (T01) Overall, empathy is widely recognized as a respect for life and the foundation of the doctor-patient relationship, encompassing both emotional and cognitive aspects. On the emotional level, it is manifested as care, sympathy, and resonance for patients; on the cognitive level, it requires an understanding of patients' situations, needs, and viewpoints. The two aspects are intertwined and jointly constitute the basic connotation of empathy.

In terms of multi-dimensional attributes, different groups have distinct understandings and perceptions. Medical students gradually recognize the existence and differences between emotional empathy and cognitive empathy during the process of learning theoretical knowledge and participating in clinical internships. Some medical students said: "Sometimes when I see patients in pain, I feel uncomfortable myself. This is emotional empathy, I guess. But to really help them, I have to understand their conditions and thoughts. That's cognitive empathy. I think both are quite important." (S01)Practicing doctors can more profoundly experience the roles of emotional empathy and cognitive empathy in different clinical situations in their actual work. For example, when facing orthopedic patients, a practicing doctor mentioned: "I am engaged in orthopedics. In our field, many patients come for consultations due to neck, shoulder, waist, and leg pain. For these patients, we need to be patient. For instance, if they walk slowly, we should wait for them and gently remind them. When conducting physical examinations, we should be more gentle in our movements. And when we need to touch the parts that cause them pain or perform actions that may cause pain, we should remind them in advance." (D08)Medical teachers guide students to analyze the application of the two types of empathy in different situations. A medical teacher pointed out: "For medical students, first of all, their emotional perception needs to be strengthened. On this basis, through the setting of some courses, such as our Medical Ethics course and Doctor-Patient Communication Skills course, etc., these courses are very helpful for their communication skills. Because in the doctor-patient relationship, effective communication is the foundation for establishing a good doctor-patient relationship and avoiding medical disputes." (T03)Emotional empathy is mainly manifested in the ability to resonate with patients' emotions and feel their joys, sorrows, and pleasures. Cognitive empathy, on the other hand, focuses on understanding patients' ways of thinking, cognitive levels, and their views on diseases and treatments, thereby providing more accurate and effective medical services and communication.

The contradiction of empathy is manifested in all three groups, and they all realize the importance of regulating empathy. In the early stage of contacting patients, medical students may have strong emotional reactions due to empathy, but they also worry that such emotions will affect their learning and judgment. A medical student said: "I think the most important aspects of empathy are patient listening and a sense of propriety. Propriety means being empathetic, but not overly empathetic. There are many cases where a patient passed away, and the doctor cried. The family members, upon seeing this, thought it was due to the doctor's improper operation and took him to court. You need to ensure that you are not indifferent and do not ignore others' feelings, but at the same time, you must remain calm. That is, when something happens, you can't be in a hurry and start crying just because of emotional excitement. You still need to maintain professional ethics and stay calm. In other words, empathy should be based on maintaining professional rationality." (S07)Practicing doctors face greater pressure. On the one hand, they need to empathize with patients, and on the other hand, they need to maintain professional calmness and objectivity. A practicing doctor frankly admitted: "I find that empathy itself has contradictions. In our career, whether we really need empathy or how to understand empathy is a relatively big question in our medical industry now." (D02)Medical teachers need to teach students how to deal with the contradictions in empathy. A medical teacher said: "For medical students or doctors with relatively low years of employment, they may be capable of emotional empathy, but they may lack some cognitive empathy. Due to their possible lack of some social knowledge, they may not be able to understand the patients' situations very well." (T02)The contradiction of empathy is mainly manifested as excessive empathy may lead to emotional exhaustion and decision-making bias of medical service providers themselves, while insufficient empathy will affect the doctor-patient relationship and patients' treatment experience. Therefore, regulating empathy, that is, expressing empathy at the appropriate time and in the appropriate way, is a skill that medical professionals need to continuously learn and practice.

Expression of empathy

Regarding the conditions for the expression of empathy, all three groups believe that establishing doctor-patient trust is the foundation, and doctor-patient communication is an important way to promote empathy. However, there are certain differences in specific cognition and practice.The group of medical students realizes that patience is crucial for expressing empathy. A medical student mentioned: "They have observed that doctors' clinical careers are very long, spanning several decades. During this process, they will surely encounter many unruly patients, and gradually lose patience. Later, they may not show much sympathy for other patients either." (S08)Based on their experiences in the long-term diagnosis and treatment process, doctors offer a perspective on the expression of empathy from the aspect of creating a ward environment. A senior doctor stated: "I think empathy should also be reflected in our entire medical environment. That is, we should try to create a warm atmosphere in the medical ward. I believe the ward environment is very important. It shouldn't be too cold—hearted." (D03)Medical teachers, on the other hand, emphasize the importance of tone in the expression of empathy. A medical teacher said: "The specific forms of expression include being patient when listening. When speaking, you should not use a commanding tone as a superior. Use more positive feedback and less negative feedback." (T01).

In different environments, the ways of expressing empathy are diverse, and the three groups all have their own observations and experiences regarding this.When medical students are on clinical internships in hospitals, they will notice that doctors adopt different ways of expressing empathy according to different departments and patient conditions. Some medical students said: "For example, when dealing with some cancer patients, sometimes we can't show real sadness, but we can show positive emotions instead. In general departments, such as gynecology and orthopedics, where the situations are not extremely critical, patients may be very happy if we communicate with them sincerely." (S01)During their actual work, doctors will flexibly adjust their ways of empathizing according to patients' personalities, conditions, and treatment stages. For instance, a practicing doctor said: "I think as the relationship between the doctor and the patient changes during the process of contact, and the doctor feels a sense of responsibility. The more they interact with patients, the more aspects they can empathize with." (D01)Medical teachers will guide students to realize that there is no fixed pattern for the expression of empathy, and it should vary from person to person and from situation to situation. A medical teacher pointed out: "In departments like surgery and emergency, there are often significant doctor-patient conflicts because lives are at stake. Everyone's emotions are on edge! The expectations are high. However, surgeons and emergency doctors have a very fast-paced workday with long-hour surgeries and such. So they usually explain things in a very concise way." (T01)Whether it is the gentleness of language, patient listening, professional explanations, or other means, they all aim to make patients feel the understanding and care from doctors, thus achieving the effective expression of empathy.

The expression of empathy has significant effects in the medical process, exerting a profound influence on both treatment and the doctor-patient relationship. All three groups have a deep sense of this.Although medical students have limited clinical experience, they can still observe the positive effects of empathy expression. A medical student said: "I think the most important thing about empathy is to build a good relationship with patients. This is the crucial point. Secondly, based on this established good relationship, there may be some additional effects. It may improve the treatment outcome." (S08)Doctors have an even deeper understanding of how the expression of empathy promotes both treatment and the doctor-patient relationship. A practicing doctor confessed: "Most patients with chronic pain or chronic discomfort will eventually experience a situation where the physical condition affects the mental state, and vice versa. In this state of psychosomatic comorbidity, I believe empathy has a great impact on their disease recovery." (D01)From an educational perspective, medical teachers emphasize the importance of the effects of empathy expression. A medical teacher stated: "Therefore, by enhancing the empathy ability of medical staff, they can understand patients, put themselves in the patients' shoes, and through strengthened communication, at least reduce the occurrence of such conflicts. This leads to a very good doctor-patient relationship." (T02)The effective expression of empathy can alleviate patients' anxiety, enhance their confidence in and compliance with treatment, thereby promoting the improvement of treatment outcomes. At the same time, it can significantly improve the doctor-patient relationship and create a favorable medical atmosphere.

Factors influencing empathy ability

Medical education plays a fundamental role in the cultivation of empathy. In terms of curriculum design, the proportion and content arrangement of humanistic medicine courses in medical curricula have a significant impact on the formation of medical students' empathy. For example, some institutions have increased the class hours and practical components of courses such as doctor-patient communication skills, medical ethics, and practical training. A medical student said: "During the practical training, we are constantly reminded to be aware of protecting the patients. Therefore, our examination techniques must be very gentle. This is always emphasized because it is included in our assessment criteria." (S02) However, some medical students believe that there is still a disconnection between theory and practice in current courses. A medical teacher also pointed out: "We can't just focus on theory. We need to provide a large number of practical opportunities. Besides classroom-based role-playing, students should enhance their practical operation abilities through scenario-based education, role-playing, and practical experiences in hospitals and society." (T03)Teaching methods are equally crucial. Interactive teaching methods such as case -based teaching and role-playing enable medical students to better understand patients' perspectives and emotions. A medical student shared: "Some teachers in clinical practice will share successful cases of doctor—patient communication that happened to them. This is more persuasive than having a class taught by non-clinical teachers." (S07).

The clinical environment is a crucial place for shaping the empathy of medical staff. The working environment is a significant influencing factor. A practicing doctor said helplessly: "I think the environment is still very important. But it doesn't mean that doctors shouldn't show empathy, and it's not that we only empathize when the conditions are right. If we are to give full play to the role of empathy, the social environment needs to offer more tolerance and support to doctors." (D03)The level of the hospital also cannot be ignored. Some primary-level hospitals, which emphasize teamwork and humanistic care, create an atmosphere conducive to the expression of empathy. A medical student mentioned: "From the patients' perspective, in top-tier tertiary-A hospitals, they feel that they don't receive much humanistic care from doctors because it's like an assembly-line operation. They may think that doctors are rather indifferent and show no sympathy for them. In contrast, in primary-level hospitals, doctors may have relatively more time. They may explain things more to patients, including providing clearer explanations about psychological and physical support." (S06).

Individual personality traits have an inherent impact on empathy. Medical staff who are female, extroverted, and good at listening and expressing are often more likely to establish emotional connections with patients, thus being able to empathize better. A medical student said: "I think a person's growth experience and personality also play a certain role. Generally speaking, I personally believe that women tend to have stronger empathy than men." (S02) On the other hand, introverted medical staff may need more efforts and training to enhance their empathy.Personal experience and exposure are also among the key factors. Senior doctors, due to having encountered more patient cases and doctor-patient interactions, usually have more mature and delicate empathy. A senior doctor lamented: "For students, the improvement of empathy often requires the accumulation of time and experience. Because for each student, their understanding of a disease, including their perception of life, aging, illness, and death, all go through a process of gradual improvement. It's not that they are strong in this regard from the beginning." (D03) In contrast, young medical students and junior-level doctors still have much room for improvement in this regard. They need to continuously practice and reflect to enrich their experiences and enhance their empathy.

Strategies for cultivating empathy ability

Cultivation strategies in the first classroom

Teachers play a leading and exemplary role in the cultivation of empathy. Medical teachers with high-level empathy themselves can subtly influence their students. A medical student recalled: "In fact, for the cultivation of doctor-patient empathy, the key figures are school teachers and clinical teaching instructors. School teachers present cases, and clinical teachers correct your mistakes. Only when you go to the clinical setting can you better put yourself in the shoes and truly understand what doctor-patient empathy really entails and how to handle the appropriate nuances. I think this is effective." (S07) Teachers can also guide students to pay attention to patients' emotional needs by interacting with students and sharing their own clinical experiences and insights into empathy.

Diversified teaching methods contribute to cultivating students' empathy. Case-based teaching is one of the commonly used and effective methods. Through real-life clinical cases, students are enabled to analyze patients' psychological and emotional states, as well as how medical staff should respond empathetically. A teacher said: "We may use some videos. Since the power of role models is significant, when teaching about empathy, we play some videos and then ask students to comment on the doctor—patient communication skills demonstrated." (T02)Role-playing is also an important approach. Students take on the roles of patients and medical staff respectively, experiencing the roles and emotions of both sides in simulated scenarios, thereby enhancing their empathy. A medical student shared: "Just like the case analysis and role-playing mentioned above. I've seen some activities carried out, and I think they are quite helpful." (S11)In addition, teaching methods such as group discussions and situational simulations can also promote communication and interaction among students, enabling them to jointly explore the practical methods and techniques of empathy.

Integrating empathy-related content into the medical curriculum system is the foundation for cultivating empathy. Besides traditional medical major courses, increasing the proportion and depth of medical humanities courses, such as medical ethics and doctor-patient communication, can systematically impart theoretical knowledge and practical methods of empathy. A doctor pointed out: "It is necessary to set up relevant courses. The course content can incorporate more practical problems and real-world challenges, which can be presented in the form of case-based problems. For example, students can role—play patients with different diseases." (D03) At the same time, empathy elements should be infiltrated into professional courses. For instance, in clinical skills training, emphasizing emotional communication and humanistic care with patients enables students to cultivate empathy while learning professional knowledge.

Cultivation strategies in the second classroom

Rich and diverse second-classroom activities provide a platform for students to practice empathy. For example, organizing students to participate in volunteer service activities, such as visiting communities and nursing homes, where they can interact and communicate with different groups of people. A doctor said: "Students should be encouraged to actively participate in club activities, whether it's student union activities or various other activities that involve interacting with people. I think all such activities are worthy of encouragement." (D02)In addition, holding activities like doctor-patient communication skills competitions can stimulate students' attention to and thinking about empathy, and enhance their empathy-expressing abilities and humanistic qualities. Moreover, emphasizing value-orientation in the second-classroom helps students establish correct concepts of empathy. Through forms such as medical humanities lectures and theme-based class meetings, students are guided to recognize that empathy is an important part of medical professionalism and reflects respect for life and care for patients.

Discussion

Analysis of the similarities and differences between this study and previous research

In the fields of medical education and clinical practice, the crucial role of empathy has been recognized by numerous studies [24, 25]. This study has also reached the same conclusion. All participants in this study agreed that empathy is the solid foundation for building a harmonious doctor-patient relationship.Regarding the dimensions of empathy, the concepts of emotional empathy and cognitive empathy mentioned in previous studies have also been strongly corroborated in this study. Moreover, these two types of empathy play different roles in different clinical situations. For example, in emergency treatment, cognitive empathy plays a crucial role, while in the long-term treatment process, emotional empathy is particularly important. In addition, the influence of educational background and clinical environment on empathy ability is also consistent with the results of previous studies [26, 27].

However, compared with some international studies, this study also shows certain differences. The impact of cultural differences on empathy is more prominent in this study. In Western cultural backgrounds, individualism prevails, and the cultivation of empathy focuses more on individual emotional expression and the improvement of self-awareness [28]. In contrast, in China, with a strong collectivist cultural atmosphere, the expression of empathy is often more implicit and reserved, and more attention is paid to the harmony of interpersonal relationships and the maintenance of the overall atmosphere [29]. In terms of the effectiveness of educational strategies, although internationally-used methods such as role-playing and reflective writing are also effective in this study, due to differences in culture and educational systems, Chinese students' experiences and gains from these methods are significantly different from those of foreign students. For example, when Chinese students engage in role-playing, they may consider collective interests and the opinions of others more, thus affecting their understanding and practice of empathy. When doing reflective writing, they are also influenced by the introverted thinking in traditional culture, and have unique characteristics in terms of expression and depth of reflection.

Exploration of the potential causes of the differences

In China, the collectivist cultural tradition has a long-standing history. In interpersonal communication, people are accustomed to paying attention to the feelings of others and pursuing group harmony. In the medical context, when doctors express empathy, they will take into account the patients' feelings and avoid straightforward emotional expressions. Patients also tend to feel cared for from the overall doctor−patient relationship rather than from a single individual's emotional expression. Such cultural differences make empathy different from Western studies in terms of definition, manifestation, and cultivation models [30].

The medical education system in China differs from that of foreign countries in terms of curriculum design and teaching methods. Medical education in China places relatively more emphasis on the imparting of theoretical knowledge. Although methods for cultivating empathy have been introduced in practical teaching, limitations in teaching resources and time may affect the implementation effect of educational strategies [31].

In the Chinese medical environment, cultural norms significantly influence the expression and expectation of empathy. The values of "benevolence" and "harmony" advocated by Chinese culture prompt doctors to treat patients with a gentle and patient attitude in clinical practice, and attach importance to listening to and understanding patients' demands. Patients also regard doctors' empathetic performance as an important criterion for measuring the quality of medical services [32].

However, with the development of globalization and the increase in medical exchanges, Western medical concepts are constantly pouring in, colliding with local Chinese culture. Against this backdrop, medical education faces the challenge of how to inherit excellent local cultural traditions while drawing on international advanced experience in empathy cultivation. In the future, we need to fully consider cultural factors in medical education and clinical practice, formulate empathy-cultivation strategies that are in line with China's national conditions, improve the quality of medical services, and promote the harmonious development of doctor-patient relationships.

Conclusion

Core findings

Through a cross-group analysis of medical students, doctors, and medical teachers, this study reveals the complexity and multi-dimensional characteristics of empathy in medical education. The research results indicate that empathy is not merely a single emotional or cognitive ability but a comprehensive skill that encompasses two main dimensions: emotional empathy and cognitive empathy. Emotional empathy involves resonating emotionally with patients, while cognitive empathy focuses on understanding patients' psychological states and backgrounds and making rational responses based on this [33].

Based on in-depth interviews with different groups, this study discovers that empathy abilities exhibit significant dynamics during the medical education process. In the initial stage, medical students often demonstrate high emotional empathy. They enhance their sensitivity to patients' needs through role-playing and simulated patient experiences. However, as their clinical experience accumulates, they gradually develop stronger cognitive empathy to meet the demands of complex clinical decision -making. This transformation reflects the adaptive mechanism of medical education in helping students balance emotions and rationality in clinical practice [34].

Furthermore, the study uncovers cultural differences in empathy abilities, especially those between Western and traditional Chinese medicine. Western medicine places greater emphasis on rational analysis and scientific diagnosis, while traditional Chinese medicine highlights emotional communication and holistic care. Such cultural differences provide a new perspective for understanding the complexity of empathy, suggesting that we should consider the diversity and complexity of cultural backgrounds in empathy education.

Practical implications for medical education

This study offers practical application value and guidance for medical educators in designing curricula and enhancing empathy in practice. The following are specific practical suggestions:

Curriculum Design and Teaching Content: Medical curricula should systematically cover both emotional and cognitive empathy. Courses such as "Medical Empathy" should be added, and the integration of relevant content in courses like medical ethics should be deepened to enable students to comprehensively understand empathy. Additionally, characteristics and needs of patients from different cultures should be introduced, and cross-cultural case-analysis courses should be set up to enhance students' cross-cultural empathy awareness and capabilities.

Teaching Methods and Practical Teaching: Adopt methods such as case-based teaching, role-playing, and group discussions. Optimize clinical internships, guide students to establish doctor-patient trust, and encourage them to record and reflect on their empathy-practice experiences. Attach importance to the second classroom. Organize volunteer activities, hold competitions, and strengthen value-orientation through lectures and other means to cultivate students' values of caring for others, contributing to society, and empathy concepts.

Teacher Training and Competency Improvement: Organize teacher training programs, invite experts to give lectures, and encourage teachers to engage in self-reflection and practice, setting good examples for students. Train teachers to innovate teaching methods, strengthen clinical practice guidance, collaborate with departments to design projects, and provide timely guidance to students.

Educational Evaluation and Feedback Mechanisms: Establish a comprehensive and scientific empathy-ability evaluation system that covers multiple aspects of indicators and adopts diversified evaluation methods. Provide timely feedback on evaluation results, offer personalized guidance, and encourage students to communicate and share, so as to jointly improve their empathy abilities.