Exploring the Development of Clinical Empathy among Chinese Medical Students: A Transition from Simulation-based Learning to Clerkship

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This study investigated the development of clinical empathy among medical students from simulation-based learning to clerkship in China. Methods: In a constructivist paradigm, this study employed an exploratory qualitative approach, adhering to the COREQ. Data were collected through semi-structured interviews with eight fifth-year medical students and observations of 26 instances among 16 fourth-year students in a six-station objective structured clinical examination. Thematic analysis was used to analyse the qualitative data. Results: In simulation-based learning, medical students focused on improving their clinical skills, seldom perceiving simulators as patients they might encounter in clinical settings, and pretended to show empathetic concern as needed. Furthermore, due to the lack of timely simulator feedback, medical students easily overlooked critical steps in clinical procedures. During clerkship, medical students experienced stronger emotional responses. Concern about potentially harming patients made students more cautious in procedural steps. Medical students gradually recognized patients’ uniqueness, becoming attuned to emotional cues and alleviating patient suffering by improving their clinical skills. Moreover, their perspective on patients shifted, enabling them to see patients as a whole to carry out medical procedures with empathetic concern. Conclusions: While simulation provides skill training, its procedural nature limits empathy development. Clerkship, in contrast, fosters medical students’ emotional engagement, individualized thinking, and flexible views of patients. Medical students Clinical empathy Medical education Simulation-based learning Clerkship Figures Figure 1 Introduction Clinical empathy is defined as a primarily cognitive attribute that involves understanding the experiences, concerns, and perspectives of patients, combined with the ability to communicate this understanding and the intention to help (Hojat, 2016 ). Clinical empathy can increase patients’ satisfaction, improve treatment adherence, lead to better clinical outcomes, and reduce patients’ emotional distress (Brown et al., 2022 ; Fragkos & Crampton, 2020 ). Moreover, clinical empathy is closely associated with improved diagnostic accuracy, enhanced physician well-being, and reduced medical risk (Bellini & Shea, 2005 ; Kelm et al., 2014 ; Neumann et al., 2011 ). Policy reforms at the institutional level provide clear guidance (e.g., AAMC’s guidelines for medical schools) for medical schools to prioritize empathy in the learning context (Ekman & Krasner, 2016 ). In medical education, scholars have widely recognized clinical empathy as a multidimensional construct (Stepien & Baernstein, 2006 ). Specifically, the moral dimension reflects the intrinsic motivation of healthcare professionals to empathize, the emotive dimension refers to the ability to subjectively experience and share patients’ emotions, the cognitive dimension pertains to the ability to recognize and understand patients’ emotions and perspectives, and the behavioural dimension involves the ability to communicate this understanding and emotional responsiveness to patients (Mercer & Reynolds, 2002 ). Studies have consistently demonstrated that clinical empathy (the emotive, cognitive and behavioural dimensions) is teachable and can be improved among medical students through interventions such as communication training (Dubosh & Carter, 2024 ; Yuen et al., 2023 ), reflective practices (Brown et al., 2022 ), and role model establishment (Yazdi et al., 2019 ). Researchers have proposed that medical students’ empathy develops dynamically and may be influenced by specific contextual moments on the educational continuum (Yazdi et al., 2019 ). On the basis of a systematic review of studies on medical students’ empathy, Krishnasamy et al. ( 2019 ) further suggested that interactions among students, patients, and learning contexts shape students’ understanding and mastery of clinical empathy and proposed a framework for cultivating empathy that emphasizes this interplay. This framework highlights the potential differences between learning contexts in empathy development, suggesting that simulation-based learning and clerkship, which are more directly connected to clinical settings than to traditional classroom teaching, may better prepare students to apply empathy in real clinical contexts and maintain a human-centred perspective of patients (Krishnasamy et al., 2019 ). Building on this framework, it is essential to consider how different learning contexts—such as simulation-based learning and clinical internships—contribute to the development of clinical empathy. By examining these learning contexts, we can better understand the mechanisms through which medical students cultivate and integrate empathy into their professional identity. Despite the growing body of research on clinical empathy in medical education, significant gaps in understanding how this critical ability develops across educational contexts remain. While Undergraduate Medical Education (UME) systems vary globally, most follow the Flexnerian bifurcation between the basic biomedical education phase and the clinical education phase (Ebert, 1992 ). Clinical empathy is cultivated primarily during the clinical education phase through two key contexts—simulation-based learning and clerkship rotations. Existing studies examine these environments predominantly in isolation, with studies focusing on the former reporting positive effects of specific types of simulation-based teaching in enhancing clinical empathy (Chua et al., 2021 ; Hashim et al., 2024 ; van Baal et al., 2023 ), whereas research on clinical clerkship highlights empathy erosion attributed to clinical reality shocks (Neumann et al., 2011 ). This fragmentation obscures the following crucial question: how do medical students adapt their empathy as they transition from structured simulations to the complexities of real-world clerkship? This gap calls for further investigation into the developmental trajectory of empathy across these key educational contexts. In the present study, we defined clinical empathy as a dynamic ability with multilevel dimensions, involving medical students’ ability to understand patients’ thoughts (cognitive) and emotional experiences (emotive) and respond appropriately (behavioural). We focused on the development of medical students’ clinical empathy during UME with China as a case example. In China’s UME system, medical students typically spend the first three years in basic biomedical education, followed by a fourth year focused on preclinical training that includes simulation-based learning and a fifth year dedicated to clinical clerkship. Accredited by the World Federation for Medical Education (WFME), China's UME system follows internationally recognized standards and has also established its own accreditation standards for basic medical education in China (Ministry of Education, 2020 ), emphasizing core competencies such as clinical empathy (Working Committee for the Accreditation of Medical Education, 2022 ). To examine the developmental trajectory of clinical empathy, this study adopted a qualitative approach. Data were gathered via semistructured interviews with eight fifth-year medical students and observations of 26 clinical skill assessments involving 16 fourth-year students. The study investigated (1) how simulation-based and clinical clerkship contexts shape students' clinical empathy and (2) how clinical empathy develops during the transition from the former to the latter learning context. Methods Study Design This study adopts a constructivist paradigm, which acknowledges that knowledge and meaning are socially constructed rather than objectively discovered (Rees et al., 2020 ). Our interview data reflect participants' socially constructed interpretations of their experiences rather than any "objective" or "factual" record of events. Through interviews, participants conveyed their perceptions and meaning-making processes shaped by their educational and clinical contexts. Research Settings This study was conducted within the context of clinical training for fourth- and fifth-year medical students during UME. After completing two to three years of foundational training in medical school, the students continued their training in hospital settings. The fourth-year medical students lived and received preclinical training in the hospital and took part in internships. Before advancing from clerkship to internship in their fifth year, they had to pass an assessment designed to evaluate their proficiency in clinical skills, which was usually administered at the hospital’s Clinical Skills Training Center at the end of the fourth year of training. The exam consisted of six stations, each lasting ten minutes, with students completing the full circuit in one hour. The stations covered two physical examination tasks, two history-taking tasks, and two procedural skill tasks. The procedural skills stations required students to demonstrate techniques on simulation models, including mannequins, prosthetic limbs, and silicone tissue blocks. In contrast, the history-taking and physical examination stations involved standardized patients (SPs), trained actors simulating real patient scenarios. Some of the physical examination tasks required students to interact with both SPs and simulation models, such as performing a breast examination on a simulated torso. Fifth-year medical students were required to rotate through various clinical departments over the course of their one-year internship in their final academic year of UME. During each rotation, students worked under the supervision of attending physicians and senior residents, gradually taking on increasing responsibilities in patient care. Their tasks included conducting patient interviews, performing physical examinations, assisting in medical procedures, writing patient records, and participating in case discussions. Participant Recruitment We conducted semistructured interviews with 8 fifth-year medical students and observed 16 fourth-year medical students. Participants were selected using purposive sampling to ensure that they had direct clinical experience in either simulation-based learning or clerkship rotations. For the interviews, the inclusion criteria were that the student participants had completed at least six months of clinical clerkship and had actively performed clinical tasks during their training. Students who had engaged only in observation without hands-on practice were excluded from the study. The sample size for the interviews was determined on the basis of the principle of data saturation—that is, interviews continued until no new key themes emerged, ensuring comprehensive coverage of relevant perspectives to maximize the representativeness of the sample and maintain analytical rigor (Saunders et al., 2018 ). Tables 1 and 2 provide detailed demographic information on the interviews and observation participants. Table 1 Overview of Interviewees (N = 8). ID Gender Program Grade Clerkship Duration Clerkship Department Interview Data 1–1 Male Five-year Fifth 2023.6-2024.5 Undecided 2024.4 1–2 Female 5 + 3 Fifth 2023.7-2024.6 Pediatrics 2024.4 1–3 Female 5 + 3 Fifth 2023.7-2024.6 Ophthalmology 2024.4 1–4 Male Five-year Fifth 2023.4-2024.5 Obstetrics and Gynecology 2024.4 1–5 Female 5 + 3 Fifth 2023.7-2024.6 Ophthalmology 2024.4 1–6 Female 5 + 3 Fifth 2023.7-2024.6 Pediatrics 2024.4 1–7 Female 5 + 3 Fifth 2023.7-2024.6 Pediatrics 2024.5 1–8 Male Five-year Fifth 2023.6-2024.6 Undecided 2024.5 Table 2 Overview of Observed Participants (N = 16). ID Gender Physical Examination Medical History Taking Basic Procedures Number of Observations 2 − 1 Male 1 0 0 1 2–2 Male 1 0 1 2 2–3 Male 0 0 1 1 2–4 Male 0 0 1 1 2–5 Female 0 0 1 1 2–6 Female 0 0 1 1 2–7 Male 1 0 0 1 2–8 Female 1 1 1 3 2–9 Male 1 1 0 2 2–10 Female 0 1 0 1 2–11 Female 0 1 0 1 2–12 Male 0 2 0 2 2–13 Male 0 1 0 1 2–14 Male 0 1 0 1 2–15 Female 2 1 1 4 2–16 Male 0 1 2 3 Note: The numbers in rows 3-6 indicate the number of times participants were observed [Insert Table 1 ] [Insert Table 2 ] Data Collection Data were collected from April 2 to May 18, 2024, through two primary methods—semistructured interviews with fifth-year medical students and nonparticipant observations of fourth-year medical students. These methods were chosen to examine medical students’ development of empathy from simulation-based learning to clerkship. The interviews focused on the students’ cognitive and emotional empathy by exploring their perceptions and experiences, whereas the observations provided insights into their behavioural empathy by capturing how they demonstrated empathy in real clinical interactions. While the interviews provided students’ self-reported reflections on empathy, direct observation enabled researchers to capture how empathy was enacted in real-time clinical interactions. By combining these approaches, this study aimed to investigate not only how students understand and experience empathy but also how they apply it in practice. The semistructured interviews were designed to explore students’ experiences with simulators and patients in both simulation-based learning and clinical clerkship and how their empathy developed throughout their training. The interviews started with general questions about the students’ clinical internship experiences, including their departmental rotations, responsibilities, and workload. The focus then shifted to their interactions with patients, prompting reflections on significant encounters that shaped their understanding of patients’ thoughts, emotions, and needs. Next, the interviews explored their experiences during simulation-based learning, asking students to recall specific training scenarios and reflect on how these experiences prepared them for real patient interactions. Emphasis was placed on how simulation helped them develop communication skills, recognize emotional cues, and navigate patient concerns. Finally, students compared the simulation-based learning with real patient encounters, evaluating how practising on simulators influenced their ability to empathize with actual patients. This section aimed to assess the transferability of empathy-related skills from simulation to clinical practice, highlighting both benefits and limitations. Nonparticipant observation was conducted on May 18 th , 2024, during a clinical skills examination at Peking University People's Hospital. The examination consisted of six stations involving tasks such as physical examinations, history-taking, and basic clinical procedures. Students interacted with both SPs and simulation devices. The observations focused on how the students communicated with the simulators and SPs, demonstrated empathy through verbal and nonverbal behaviours, and responded to patient concerns. Particular attention was paid to signs of active listening, a compassionate tone, patient-centred questioning, and the ability to recognize and address patients’ emotions. Data Analysis We employed thematic analysis following Braun and Clarke’s (2006) framework. The analysis process included the following steps: Becoming Familiar with the Data: The research team began by reading and rereading the transcripts and observational data, focusing particularly on emotional responses and expressions of empathy in both simulated and clinical settings. Generating Initial Coding: We coded the transcripts line by line to identify recurring features related to empathy development from simulated learning to clerkship. Initial codes such as “performing a play” and “emotional engagement” were identified. Searching for Themes : After generating initial codes, we grouped related codes into potential themes. For example, we combined the codes “performing a play” and “emotional engagement” into the single overarching theme of “emotional activation. ” Reviewing the Themes : Through team discussion and further data review, we ensured that each theme was well supported by the data and that the themes accurately reflected the core aspects of empathy development. For example, for the theme “emotional activation”, we clarified how students’ emotional involvement transitioned from “play-acting” in simulated settings to deeper emotional engagement in complex clerkship environments. Defining and Naming the Themes : We clearly defined and named the themes. These definitions and names were refined to ensure that each theme clearly reflected the data and the research questions, effectively capturing the evolution of empathy in the medical students. For example, we identified the following two kinds of performances during simulated-based learning: “one-person show” and “two-person show”. Organizing the Themes : In the final report, we presented the definitions and data extracts for each theme, providing a clear narrative that linked the findings to the research question and built a conceptual framework to organize all the key themes. We also incorporated member checking by sharing the preliminary findings with two participants to confirm the accuracy and relevance of our interpretations. Their feedback was used to refine and enhance the final report. We used NVivo software 12 (QSR Internation Ltd, Version 12, 2018) to manage and organize the qualitative data. Thematic saturation was achieved when no new themes emerged from the data. Reflexivity The research team consists of scholars with diverse academic backgrounds relevant to medical education and qualitative research. The first and second authors are graduate students specializing in professional health education, with backgrounds in psychology and education, respectively. Both authors have received formal training in qualitative research methods and have independently conducted qualitative studies. The corresponding author, an expert in the field of medical education, provided guidance and oversight throughout the research process. This multidisciplinary perspective enabled the team to critically analyse the data, incorporating both theoretical and experiential insights. The constructivist approach adopted in this study acknowledges that knowledge is socially constructed and shaped by researchers' positionalities. To enhance the credibility of the findings, the team engaged in reflexivity, continuously reflecting on their roles, assumptions, and potential biases during data analysis and interpretation. Ethical Approval Ethical approval (IRB00001052-20069) was obtained from the Institutional Review Board of Peking University. All participants provided informed consent to participate. The study was conducted in accordance with the Declaration of Helsinki. Results We identified the following three key themes to compare how the medical students in the sample expressed empathy towards medical simulators in simulated settings and patients during clerkship: (1) emotional activation, (2) procedural thinking, and (3) perspective on patients. In addition, we constructed a conceptual framework to organize these themes, as shown in Figure 1, which are described in more detail as follows: emotional activation: from “play-acting” in the simulated environment to emotional engagement in the complex clerkship; procedural thinking: from results-oriented process thinking to understanding differences among patients; and perspectives on patients: from a task-oriented localized view to empathetic care for patients as a whole. [Insert Figure 1] Emotional Activation: From “Play-Acting” in the Simulated Environment to Emotional Engagement in the Complex Clerkship Although simulation-based learning aims to recreate clinical settings as realistically as possible to offer learning opportunities, the simulated environment cannot fully replicate real clinical situations. During these exercises, students followed a procedural routine. When they were interviewed about simulation learning and simulation-based assessments, every participant used the term “performance.” For example, "Our teacher told us to care for patients, so we incorporated that into our performance, something like that" (1-2).” "When doing it on a model, it doesn’t feel very real, like I'm acting" (1-5). “ When working on a dummy during simulation, we just perform the action of covering them with a blanket because that’s required but not to protect their privacy or prevent them from getting cold as doctors will do on real patients ” (1-2). Moreover, because actions performed in the simulations did not have real clinical consequences, students often focused more on completing the exam and meeting assessment criteria, reinforcing a procedural mindset. For example, when examining a prosthetic arm, as the students knew that the arm would not feel pain, they did not develop empathy for it. However, in an attempt to meet the humanistic care requirements of the exam, they behaved as if they understood the feelings of the patients. They chose different ways to demonstrate this understanding. Some students reported directly to the examiner in the third person (e.g., in 2-5, " I told the patient that the wound might hurt and advised her to rest "). Others spoke to the simulated patient in the first person as if they were talking to a real patient (e.g., in 2-3, " Your wound is healing well, with no discharge or complications "). Students’ performance level also varied. For example, during an emergency simulation with a dummy, some students showed tension by anxiously shouting "Zhang, Zhang, what happened?" while patting the dummy's shoulder (2-2). Others expressed tension with repetitive phrases such as "Sir, sir, are you okay?," while some students calmly asked "Sir, can you hear me?" (2-6). However, the medical students commonly recalled feeling nervous during their first clinical procedures on real patients. Although the students in their fifth-year clerkship phase had typically performed only low-risk procedures, many of them had practised these procedures during simulation-based learning. The nervousness stemmed mainly from the fear of harming the patient or causing a direct adverse outcome. Examples of this fear included the following: " The C-section incision in obstetrics is large, and I was afraid of hurting her" (1-2); "Afraid of damaging the birth canal " (1-4); " Sometimes when clamping cotton balls, I'm afraid I might accidentally hurt the patient's wound " (1-5); " I hadn’t operated on a real person before, and I was afraid it would hurt them a lot " (1-6); and " I had never tried it on a real person " (1-3). There was also concern about breaking the sterile field, potentially harming the patient indirectly, as follows: " I was afraid of contaminating the sterile field " (1-2), " I'm most worried about contamination " (1-6), and " I didn’t dare move, didn’t dare touch... the most important thing is you can’t touch anything, or you’d have to stop because you'd have violated the sterile field " (1-6). Unlike in simulation practice, where there are no real clinical consequences, this anxiety is common in real clinical settings but does not usually hinder students’ performance, and it typically fades after students perform a few procedures on real patients. Procedural Thinking: From Outcome-Oriented Process Thinking to Understanding Differences among Patients As the medical school required the students to demonstrate empathetic care, students often performed to show that they understood the situation or symptoms that simulated patients were experiencing. We identified two kinds of performance, "one-person show" and "two-person show". In "one-person shows" , the students worked with simulated dummies, prosthetics, or silicone models; these devices did not provide feedback, and the students needed to follow a set procedure to show their clinical skills. In these circumstances, we observed that students inevitably "forgot steps". During an emergency resuscitation exam, all four students correctly answered that the patient’s head should be tilted back, but when faced with a dummy whose head was elevated by a pillow placed there by the examiner, only one student (2-8) removed the pillow. During wound dressing exams, students used contaminated forceps to pick up sterile cotton balls (2-3), touched sterile cotton balls with their fingers (2-4), and placed scissors on a sterile tray (2-16), failing to adhere to sterile techniques. However, when asked about wound dressing and suture removal in real clinical settings, all the interviewees emphasized the importance of "not breaking sterile principles". In "two-person shows" , standardized patients (SPs) could respond to students' questions and actions during physical exams and medical history interviews. In these cases, the students could pick up "exam clues" from the SPs’ responses and adjust their answers accordingly. The forgetting that occurred in the one-person show was less common in the two-person show. During the observations, the same medical student at the same exam station, requiring both a simulated chest organ and interaction with an SP, asked the SP questions such as "Does this hurt?" and said, "Please try to relax" while examining the SP, but when examining the simulated organ, the student proceeded without interacting, simply reporting the results as follows: "No swelling in the breast, some discharge from the right nipple" (2-9). Similar situations were observed with other students (2-15). As one student explained, "I needed to do an axillary dissection, and for that, the patient's arm must be positioned a certain way, but my model didn’t have an arm, so I completely forgot to position it and just proceeded with the operation" (1-2). Other interviewees shared similar experiences, such as "It feels more real and flows better when working with a real person than on a model" (1-5). Unlike simulation-based learning, clerkship required students to face actual patients rather than standardized models and patients. Each patient was unique, differing significantly from those in simulated scenarios. Consequently, the students had to adapt their procedures accordingly. First, there was a difference between equipment and real people. Procedures on models were more rigid because the equipment could not fully replicate the complexity of real-life situations. For example, during urinary catheterization, the catheter stayed fixed once inserted into a model, but when the procedure was performed on a male patient, it could bounce back if it was not fully inserted (1-5). The models were standardized, but in real patients, factors such as subcutaneous fat (1-2), tissue growth (1-1), and pain tolerance (1-6) differed, requiring adjustments in the procedure. For example, the students might need to double check whether the catheter is inserted correctly. Clinical complexities could include issues such as tightly tied suture ends that were difficult to remove, causing the patient to cry out in pain (1-2), or a tightly adhered adhesive causing discomfort, requiring the student to slow down and reassure the patient (1-6). Although the assessment requirements were well defined in the simulations, in real clinical practice, students needed to interpret imaging data before performing a procedure, such as determining the location of pleural effusion for a thoracentesis, with one student stating that "The models are too rigid for this" (1-4). Furthermore, in clinical settings, students needed to account for patient preferences. Patients were no longer passive objects of operation but could ask questions, and students could not predict what they would ask, leading to unexpected scenarios. For example, while performing suturing on a thyroidectomy patient, since the wound was on the neck—a visible area—students needed to perform subcutaneous suturing, which was a more difficult technique than what they had learned (1-8). During a lumbar puncture, a patient might express discomfort, prompting the student to stop and seek help from their supervisor (1-1). Although the students had learned how to take medical histories, in real clinical settings, patients’ responses might not follow the logical sequence from class. As one student noted, "They jump from one topic to another, and suddenly, you don’t know what to ask anymore" (1-2). Students could also learn from their clinical instructor, especially when they entered the clinical setting at the beginning, knowing little about how to comfort patients and provide care. As one student stated, “ My instructor will tell me to consider patients’ status and show me how to do this. Sometimes, patients express concerns about being unable to afford medical expenses. The instructor will keenly pick up these details and introduce them to medications that qualify for higher medical reimbursement. This way, patients can feel less worried about the financial burden. Then , I will know how to deal with similar circumstances” (1-2). Perspectives on Patients: From a Task-oriented Localized View to Empathetic Care for Patients as a Whole In clinical practice, the medical students often shifted between focusing on "local" and "global" perspectives while treating patients. Clinical procedures were divided into steps, with different tasks requiring different perspectives. In the operating room, only the area being operated on was exposed, with the rest of the patient’s body covered by sterile drapes. The procedure itself was performed on localized tissue, and students adopted a highly focused, localized perspective. For example, as one student noted, "You only see the exposed part needed for the surgery, which could be just a section of the abdomen, and at that moment, you’re really only seeing tissue, not the whole person" (1-5). This localized perspective became more prominent during processes such as cutting and separating tissues as follows: "When I saw the thyroid gland being cut away, I felt an even stronger sense of focusing on just that small area" (1-7). This is a process of "targeting the problem”, where a specific lesion is removed, and as a result, other symptoms caused by the lesion also improve (1-8). However, once the surgery was complete and suturing began, the students shifted to a more global perspective, focusing on restoring the patient’s body to its original state as follows: "As I sutured each layer back together, I gained a sense of wholeness" (1-7). Suturing was seen as a way to return the patient to as close to normal as possible. Thus, "The goal is to help the patient’s overall condition recover as much as possible" (1-7). How did students switch between focusing on the local and the global? One student offered the following analogy: "It’s like being familiar with a school—you know exactly where you are at any given moment while walking from your dorm to the cafeteria, but in the moment, you’re focused on walking and watching the people and cars around you" (1-8). During local procedural tasks, their attention was turned to the patient’s tissues and organs. For medical students with limited experience, even this local information could be overwhelming, making it difficult to focus on anything else. Although they understood that the patient was a whole person, during the procedure, they tended to "not think about it too much" and "empty their minds" (1-8). Additionally, patient feedback reminded the students to view the patients as whole persons rather than just body parts. All the respondents noted that when changing bandages or removing sutures in the ward, it was impossible to treat the patient as a disjointed part. Simulation equipment may have mimicked only specific body parts, but in real clinical practice, the surrounding environment and patient reactions also influenced the students. For example, while a medical student was changing a dressing on the inpatient ward, a patient might complain of pain, and nearby patients might watch nervously (1-2). Furthermore, the protocols of the clinical environment encouraged students to view patients holistically. While students were suturing in the operating room, external cues such as hearing the patient’s heart rate monitor or monitoring equipment might remind them of the patient’s overall condition. During simulations, however, multiple students might work on a model at the same time, diminishing the sense of a real clinical environment (1-8). In simulations, students focused solely on the technical task, but with real patients, considerations such as presurgery evaluations and postop care also made students aware of the need for aesthetic suturing to improve patient outcomes. Discussion Both simulation-based learning and clinical learning have unique advantages in developing clinical empathy among medical students, and these two items are complementary. Simulation learning offers a safe practice environment for medical students to familiarize themselves with clinical procedures, such as mastering patient interview techniques. Additionally, by repeatedly practising empathy in simulated scenarios using standardized patients and models, students develop a deeper appreciation for patient-centred care and the importance of empathetic interactions in clinical practice. During clinical clerkship, medical students cultivate empathy by directly interacting with patients, actively listening to their concerns, and gaining a deeper understanding of their needs and emotional experiences. Experiencing real-life patient encounters shows students the human impact of medical care, fostering emotional connection and perspective-taking. Additionally, as they recognize their responsibility for patient outcomes, they develop a stronger sense of accountability, which reinforces their ability to empathize with patients and respond with compassion in clinical practice. Simulation-Based Learning: Standardized Practice in a Safe and Controlled Environment Simulation learning in medical education provides a safe and controlled environment where students can practice and improve without risk. This environment helps reduce students’ psychological pressure, allowing them to focus on learning essential clinical and empathy skills. According to situational learning theory, the learning environment significantly influences learning outcomes. The simulated clinical environment aids students in applying their knowledge and skills during real-world practice (Dawley & Dede, 2014; Lunce, 2006). In this setting, students can freely explore and gradually build confidence in their empathy skills. In addition, through repeated practice and successful experiences in simulation-based learning, students gradually develop self-efficacy. Bandura's (1977) theory of self-efficacy states that self-efficacy refers to one’s confidence in successfully completing a task. In the low-pressure environment of simulation, students can practice clinical skills repeatedly, gain proficiency and experience success, not only enhancing their self-efficacy but also allowing them to confidently apply these skills when facing real patients. Clinical Clerkship: Professional Development in Real-World, Dynamic Workflows The clerkship period, as a critical phase in the professional socialization process of medical students, shapes how they interact with patients, colleagues, and the broader healthcare system (Chandran et al., 2019). In particular, learning in clinical clerkship settings is widely regarded as the “gold standard” of clinical education for fostering empathy, offering unparalleled advantages (Nyoni et al., 2021; Partner et al., 2022). In modern medical practice, empathy has evolved beyond being merely an emotional response; it is now recognized as an essential professional competency that is systematically and normatively integrated into healthcare processes. This professionalized form of empathy requires medical students to not only understand and respond to patients’ emotional needs but also incorporate empathy into every stage of clinical decision-making, ensuring the comprehensiveness and personalization of healthcare services. This empathetic process reflects students’ profound respect and care for patients in professional practice, as well as the implementation of patient-centred care within a framework of institutional support. In a real clinical environment, medical students receive feedback from patients and health care team members. This feedback goes beyond technical evaluation, also encompassing emotional and attitudinal aspects. Patients’ real reactions help students better understand the significance and impact of empathy in medical practice. Kolb’s (1984) experiential learning theory indicates that feedback obtained through concrete experiences and reflection greatly enhances learning and skill development. By engaging in real-world clinical practice, medical students can accumulate valuable experience and improve their clinical skills, including empathy (Gavigan, 2010; O’Neill, 2010). In addition, clinical instructors play a key role in shaping medical students’ empathetic abilities, which is consistent with findings from previous studies (Yazdi et al., 2019). By observing and imitating instructors' interactions with patients, students can learn how to apply empathy skills in actual clinical scenarios. Instructors’ behaviour, methods for handling patients’ emotions, and caring attitude serve as exemplary models. Close collaboration with instructors enables students to better understand and master the practical application of clinical empathy. Insights for Clinical Empathy Education in Medical Training Medical education curricula should integrate both simulation learning and clinical clerkship to ensure that students develop clinical empathy at different stages. Simulation learning usually focused more on building strong foundational skills and empathy techniques, whereas clerkship could prioritize real patient feedback and clinical outcomes to further enhance empathy. In the preclinical phase, simulation-based learning is used to develop solid clinical and empathy skills, whereas during the clerkship phase, emphasis is placed on enhancing medical students’ empathy through feedback from real patients and clinical outcomes. Helping medical students better connect simulation exercises with real clinical scenarios in the simulation learning environment may further aid their understanding of the teaching design’s objectives, thereby improving training outcomes. Additionally, though the present study didn’t find that empathy declines as students transited into clerkship, it is necessary to emphasize the requirement for medical students' empathic abilities in simulated learning environments (e.g., assigning a higher weight to empathy scores in clinical skills assessments). This approach can help medical students establish the crucial understanding that empathy is vitally important before entering clinical practice. Comparatively, while clinical skills will continue to be honed after entering clinical settings, empathic abilities may become neglected amidst busy clinical work as workload is negatively related to clinical empathy (Chi et al., 2024). Cultivating higher levels of empathic competence and awareness during early training can empower medical students to maintain high-quality empathic care for patients even when confronted with demanding workloads. A recent research also highlights that incorporating medical improvisation into curricula can improve medical students’ empathy skills (Herber-Valdez et al., 2024). However, the design of such exercises must align with learning aims; otherwise, there may be a disconnect between the exercises and teaching goals (Chan et al., 2024). Additionally, considering the limitations of simulation tools, such as insufficient realism and a lack of personalized feedback, establishing a systematic mechanism for reflection and feedback is crucial, as it allows students to engage in continuous self-reflection and improvement through both simulation-based learning and clinical clerkship. Consistent with previous findings (Yazdi et al., 2019), this study revealed that clinical educators play a vital role in students’ development of clinical empathy. Institutions should strengthen training and support for clinical educators to improve their teaching abilities and increase their empathy, providing students with exemplary clinical role models. During clinical clerkship, clinicians can also offer courses on clinical communication and empathy so that medical students can learn these skills from instructors. For example, a medical school in Germany provides courses on doctor‒patient communication skills during the clerkship phase. A study of this program showed that although the students experienced increased work stress in the clinical environment, their empathy levels did not decline (Roling et al., 2020). Furthermore, teaching medical students communication skills for discussing diseases during internal medicine clerkship can enhance their sense of efficacy in doctor‒patient communication and promote the development of empathy skills (Yuen et al., 2023). Limitations and future research From the perspective of interaction with patients, the present study provides some evidence to facilitate understanding the development of medical students' empathy across different teaching contexts, but it also has the following limitations. First, our interviews with eight fifth-year medical students were retrospective, asking them to recall their experiences with simulated learning before entering clerkship and their experiences with real patients. We examined the development of and changes in the students' empathy across these two distinct stages. However, subsequent experiences may have influenced the students' perceptions and attitudes during the recall process. Fortunately, we supplemented our data with observations of 16 preclinical fourth-year medical students. Their experiences interacting with simulated patients can be considered less influenced by their clinical experiences. Future research could consider designing a longitudinal study with intensive data collection (e.g., audio diaries), which would reduce the risk of information loss and address concerns about data richness (Morishita et al., 2023). In addition, this design could better capture the dynamic development of medical students' empathy abilities from simulated learning to clinical practice (Balmer et al., 2021). A second limitation of this study is related to our selection of research participants. While we focus on medical students, their limited learning experiences and life experiences mean that their understanding of empathy is still evolving. Finally, in this study, we interviewed only medical students and did not ascertain whether the behaviours and reactions they mentioned were perceived by patients as empathetic or merely superficial emotional expressions. Future research could consider supplementing patient interviews and matching the data from medical students and patients. Conclusion This study revealed that medical students’ clinical empathy exhibited different characteristics in simulation learning and clinical clerkship contexts. In the simulation environment, empathy was more of a performance based on the scenario, whereas in the clinical environment, it was more easily triggered by patients’ identity traits, evoking a stronger empathetic response from students. Declarations Funding The study was funded by the National Natural Science Foundation of China (Grant Number: 72174013). Author Contribution Researchers H.C. and H.W. performed the conception and design of the work. H.Z. conducted data collection, contributed to quantitative data analysis and drafted the first version of the manuscript. Z.S. contributed to interpretation of data and revised the manuscript. All authors contributed to the selection and interpretation of data, drafting and critical revision of the manuscript. All authors read and approved the final manuscript. All authors agreed to be accountable for all aspects related to the manuscript. Haichun Zhou (H.Z.): methodology, data curation, formal analysis, investigation, writing – original draft (preparation), visualization. Ziyue Shen (Z.S.): conceptualization, formal analysis, writing – reviewing and editing. Hongbin Wu (H.W.): conceptualization, writing - reviewing and editing, supervision. References Balmer, D. F., Varpio, L., Bennett, D., & Teunissen, P. W. (2021). Longitudinal qualitative research in medical education: Time to conceptualise time. Medical Education , 55 (11), 1253–1260. https://doi.org/10.1111/medu.14542 Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review , 84 (2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191 Bellini, L. M., & Shea, J. A. (2005). Mood Change and Empathy Decline Persist during Three Years of Internal Medicine Training. Academic Medicine , 80 (2), 164. https://doi.org/10.1097/00001888-200502000-00013 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3 (2), 77–101. https://doi.org/10.1191/1478088706qp063oa Brown, M. E. L., MacLellan, A., Laughey, W., Omer, U., Himmi, G., LeBon, T., & Finn, G. M. (2022). Can stoic training develop medical student empathy and resilience? A mixed-methods study. BMC Medical Education , 22 (1), 340. https://doi.org/10.1186/s12909-022-03391-x Chan, C. A., Windish, D. M., Spak, J. M., & Makansi, N. (2024). State-of-the-art review of medical improvisation curricula to teach health professional learners communication. Advances in Health Sciences Education , 29 (3), 1025–1046. https://doi.org/10.1007/s10459-023-10296-x Chandran, L., Iuli, R. J., Strano-Paul, L., & Post, S. G. (2019). Developing “a way of being”: Deliberate approaches to professional identity formation in medical education. Academic Psychiatry , 43 , 521–527. https://doi.org/10.1007/s40596-019-01048-4 Chi, D., Yu, H., Wang, Y., Du, X., Ma, H., & Zhang, Y. (2024). The role of empathy and self-compassion in the association between workload and burnout in psychiatric professionals. Asian Journal of Psychiatry , 92 , 103888. https://doi.org/10.1016/j.ajp.2023.103888 Chua, J. Y. X., Ang, E., Lau, S. T. L., & Shorey, S. (2021). Effectiveness of simulation-based interventions at improving empathy among healthcare students: A systematic review and meta-analysis. Nurse Education Today , 104 , 105000. https://doi.org/10.1016/j.nedt.2021.105000 Costa, P., Magalhães, E., & Costa, M. J. (2013). A latent growth model suggests that empathy of medical students does not decline over time. Advances in Health Sciences Education , 18 , 509–522. https://doi.org/10.1007/s10459-012-9390-z Dawley, L., & Dede, C. (2014). Situated learning in virtual worlds and immersive simulations. Handbook of Research on Educational Communications and Technology , 723–734. https://doi.org/10.1007/978-1-4614-3185-5_58 Dubosh, N. M., & Carter, K. (2024). Teaching Trainees Effective Patient Communication Skills in the Clinical Environment: Best Practices under Crisis Conditions. Academic Medicine , 99 (4), 370–373. Scopus. https://doi.org/10.1097/ACM.0000000000005595 Ebert, R. H. (1992). Flexner’s model and the future of medical education. Academic Medicine , 67 (11), 737–742. Ekman, E., & Krasner, M. (2016). Empathy in medicine: Neuroscience, education and challenges. Medical Teacher , 39 (2), 164–173. https://doi.org/10.1080/0142159X.2016.1248925 Fragkos, K. C., & Crampton, P. E. (2020). The effectiveness of teaching clinical empathy to medical students: A systematic review and meta-analysis of randomized controlled trials. Academic Medicine , 95 (6), 947–957. https://doi.org/10.1097/ACM.0000000000003058 Gavigan, L. (2010). Connecting the Classroom with Real-World Experiences through Summer Internships. Peer Review , 12 (4), 15–19. Hashim, M. J., Khan, M. A., Kieu, A., Alkaabi, F. M. K., Rubaei, F. K. A. A., Alfazari, M. M. K., Alneyadi, M. A. K., Alsaedi, R. H. S., & Govender, R. (2024). Using reflective writing to enhance empathy among medical students. Canadian Medical Education Journal , 15 (2), 91–92. https://doi.org/10.36834/cmej.77172 Herber-Valdez, C. R., Blow, J. A., Salazar, T. T., Horn, K. V., Herrera, D. G., Lacy, N. L., Beinhoff, L., & de la Rosa, J. M. (2024). The integrated curriculum and student empathy: A longitudinal multi-cohort analysis. Advances in Health Sciences Education : Theory and Practice , 29 (4), 1131–1153. https://doi.org/10.1007/s10459-023-10292-1 Hojat, M. (2016). Empathy in health professions education and patient care (294 📊). https://doi.org/10.1007/978-3-319-27625-0 Kelm, Z., Womer, J., Walter, J. K., & Feudtner, C. (2014). Interventions to cultivate physician empathy: A systematic review. BMC Medical Education , 14 (1). Scopus. https://doi.org/10.1186/1472-6920-14-219 Kolb, D. (1984). Experiential Learning: Experience As The Source Of Learning And Development. In Journal of Business Ethics (Vol. 1). Krishnasamy, C., Ong, S. Y., Loo, M. E., & Thistlethwaite, J. (2019). How does medical education affect empathy and compassion in medical students? A meta-ethnography: BEME Guide No. 57. Medical Teacher , 41 (11), 1220–1231. https://doi.org/10.1080/0142159X.2019.1630731 Lunce, L. M. (2006). Simulations: Bringing the benefits of situated learning to the traditional classroom. Journal of Applied Educational Technology , 3 (1), 37–45. Mercer, S. W., & Reynolds, W. J. (2002). Empathy and quality of care. The British Journal of General Practice: The Journal of the Royal College of General Practitioners , 52 Suppl (Suppl), S9-12. Ministry of Education. (2020). WCAME awarded WFME recognition status . http://en.moe.gov.cn/news/press_releases/202006/t20200628_468685.html Morishita, M., Iida, J., & Nishigori, H. (2023). Reconstructing the concept of empathy: An analysis of Japanese doctors’ narratives of their experiences with illness. Advances in Health Sciences Education , 28 (1), 87–106. https://doi.org/10.1007/s10459-022-10143-5 Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., Haramati, A., & Scheffer, C. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine , 86 (8), 996–1009. Scopus. https://doi.org/10.1097/ACM.0b013e318221e615 Nyoni, C. N., Dyk, L. H.-V., & Botma, Y. (2021). Clinical placement models for undergraduate health professions students: A scoping review. BMC Medical Education , 21 , 1–26. https://doi.org/10.1186/s12909-021-03023-w O’Neill, N. (2010). Internships as a High-Impact Practice: Some Reflections on Quality. Peer Review , 12 (4), 4–8. Partner, A., Shiner, N., Hyde, E., & Errett, S. (2022). First year student radiographers’ perceptions of a one-week simulation-based education package designed to increase clinical placement capacity. Radiography , 28 (3), 577–585. https://doi.org/10.1016/j.radi.2022.04.007 Rees, C. E., Crampton, P. E., & Monrouxe, L. V. (2020). Re-visioning academic medicine through a constructionist lens. Academic Medicine , 95 (6), 846–850. Roling, G., Lutz, G., Edelhäuser, F., Hofmann, M., Valk-Draad, M. P., Wack, C., Haramati, A., Tauschel, D., & Scheffer, C. (2020). Empathy, well-being and stressful experiences in the clinical learning environment. Patient Education and Counseling , 103 (11), 2320–2327. https://doi.org/10.1016/j.pec.2020.04.025 Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H., & Jinks, C. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization. Quality & Quantity , 52 (4), 1893–1907. https://doi.org/10.1007/s11135-017-0574-8 Stepien, K. A., & Baernstein, A. (2006). Educating for empathy—A review. JOURNAL OF GENERAL INTERNAL MEDICINE , 21 (5), 524–530. https://doi.org/10.1111/j.1525-1497.2006.00443.x van Baal, S. T., Verdejo-García, A., & Hohwy, J. (2023). Episodic future thinking and compassion reduce non-compliance urges regarding public health guidelines: A randomised controlled trial. BMC Public Health , 23 (1), 189. https://doi.org/10.1186/s12889-023-15031-0 Working Committee for the Accreditation of Medical Education. (2022). Standards for basic medical education in China. https://wcame.meduc.cn/uploads/soft/20230308/Standards%20for%20Basic%20Medical%20Education%20in%20China--the%202022%20Revision.pdf Yazdi, N. A., Bigdeli, S., Arabshahi, S. K. S., & Ghaffarifar, S. (2019). The influence of role-modeling on clinical empathy of medical interns: A qualitative study. Journal of Advances in Medical Education & Professionalism , 7 (1), 35. Yuen, J. K., See, C., Cheung, J. T. K., Lum, C. M., Lee, J. S., & Wong, W. T. (2023). Can teaching serious illness communication skills foster multidimensional empathy? A mixed-methods study. BMC Medical Education , 23 (1), 20. https://doi.org/10.1186/s12909-023-04010-z Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6325059","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495233315,"identity":"e7b9e9eb-d903-4582-916b-74352ad93cbf","order_by":0,"name":"Haichun Zhou","email":"","orcid":"","institution":"Peking University","correspondingAuthor":false,"prefix":"","firstName":"Haichun","middleName":"","lastName":"Zhou","suffix":""},{"id":495233316,"identity":"ba2bec61-0661-462b-a492-b0c17caf8f55","order_by":1,"name":"Ziyue Shen","email":"","orcid":"","institution":"Peking University","correspondingAuthor":false,"prefix":"","firstName":"Ziyue","middleName":"","lastName":"Shen","suffix":""},{"id":495233317,"identity":"8141cee1-a4bd-4ed8-a7d8-9f3d9bdf0c97","order_by":2,"name":"Hongbin Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYFACHhBxgIeBvYEZxGJsIF4LzwEStTAwSCQQqcXgRu7BxwW/7siYS749bMzDYCO74QDzswf4teQlG8/se8ZjOTsvOZmHIc14wwE2cwN8Wsxu5JhJ8/Yc5jG4nWN8mIfhcOKGAzxsEsRpuXkGpOU/kVp4fgC13OAxBjrsAGEt9mfeGBvzNjzjMTiTl2w4xwDoscNsZni1SLbnGD7m+XPH3uD42cMSbyrsZPuONz/DqwUMGNtAJCiCQEHFTFA9CPyBaRkFo2AUjIJRgAUAAHQ/SX2qoqZtAAAAAElFTkSuQmCC","orcid":"","institution":"Peking University","correspondingAuthor":true,"prefix":"","firstName":"Hongbin","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2025-03-28 05:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6325059/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6325059/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10459-025-10497-6","type":"published","date":"2025-12-22T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88409676,"identity":"87976615-025f-484d-bd89-e7f925059a65","added_by":"auto","created_at":"2025-08-06 08:20:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62852,"visible":true,"origin":"","legend":"\u003cp\u003eThe Effect of Simulation-Based learning and Clinical Clerkships on Medical Students' Clinical Empathy.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6325059/v1/13d68d0037163d338138700a.png"},{"id":99172470,"identity":"462fd425-1576-48fe-bc3a-2f2bb5fff6d3","added_by":"auto","created_at":"2025-12-29 16:10:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1073490,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6325059/v1/9ff966b8-3df4-4492-abf6-8dee53c1bec4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the Development of Clinical Empathy among Chinese Medical Students: A Transition from Simulation-based Learning to Clerkship","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinical empathy is defined as a primarily cognitive attribute that involves understanding the experiences, concerns, and perspectives of patients, combined with the ability to communicate this understanding and the intention to help (Hojat, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Clinical empathy can increase patients\u0026rsquo; satisfaction, improve treatment adherence, lead to better clinical outcomes, and reduce patients\u0026rsquo; emotional distress (Brown et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Fragkos \u0026amp; Crampton, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Moreover, clinical empathy is closely associated with improved diagnostic accuracy, enhanced physician well-being, and reduced medical risk (Bellini \u0026amp; Shea, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Kelm et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Neumann et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Policy reforms at the institutional level provide clear guidance (e.g., AAMC\u0026rsquo;s guidelines for medical schools) for medical schools to prioritize empathy in the learning context (Ekman \u0026amp; Krasner, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn medical education, scholars have widely recognized clinical empathy as a multidimensional construct (Stepien \u0026amp; Baernstein, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Specifically, the moral dimension reflects the intrinsic motivation of healthcare professionals to empathize, the emotive dimension refers to the ability to subjectively experience and share patients\u0026rsquo; emotions, the cognitive dimension pertains to the ability to recognize and understand patients\u0026rsquo; emotions and perspectives, and the behavioural dimension involves the ability to communicate this understanding and emotional responsiveness to patients (Mercer \u0026amp; Reynolds, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Studies have consistently demonstrated that clinical empathy (the emotive, cognitive and behavioural dimensions) is teachable and can be improved among medical students through interventions such as communication training (Dubosh \u0026amp; Carter, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yuen et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), reflective practices (Brown et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and role model establishment (Yazdi et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Researchers have proposed that medical students\u0026rsquo; empathy develops dynamically and may be influenced by specific contextual moments on the educational continuum (Yazdi et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). On the basis of a systematic review of studies on medical students\u0026rsquo; empathy, Krishnasamy et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) further suggested that interactions among students, patients, and learning contexts shape students\u0026rsquo; understanding and mastery of clinical empathy and proposed a framework for cultivating empathy that emphasizes this interplay. This framework highlights the potential differences between learning contexts in empathy development, suggesting that simulation-based learning and clerkship, which are more directly connected to clinical settings than to traditional classroom teaching, may better prepare students to apply empathy in real clinical contexts and maintain a human-centred perspective of patients (Krishnasamy et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Building on this framework, it is essential to consider how different learning contexts\u0026mdash;such as simulation-based learning and clinical internships\u0026mdash;contribute to the development of clinical empathy. By examining these learning contexts, we can better understand the mechanisms through which medical students cultivate and integrate empathy into their professional identity.\u003c/p\u003e\u003cp\u003eDespite the growing body of research on clinical empathy in medical education, significant gaps in understanding how this critical ability develops across educational contexts remain. While Undergraduate Medical Education (UME) systems vary globally, most follow the Flexnerian bifurcation between the basic biomedical education phase and the clinical education phase (Ebert, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1992\u003c/span\u003e). Clinical empathy is cultivated primarily during the clinical education phase through two key contexts\u0026mdash;simulation-based learning and clerkship rotations. Existing studies examine these environments predominantly in isolation, with studies focusing on the former reporting positive effects of specific types of simulation-based teaching in enhancing clinical empathy (Chua et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Hashim et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; van Baal et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), whereas research on clinical clerkship highlights empathy erosion attributed to clinical reality shocks (Neumann et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). This fragmentation obscures the following crucial question: how do medical students adapt their empathy as they transition from structured simulations to the complexities of real-world clerkship? This gap calls for further investigation into the developmental trajectory of empathy across these key educational contexts.\u003c/p\u003e\u003cp\u003eIn the present study, we defined clinical empathy as a dynamic ability with multilevel dimensions, involving medical students\u0026rsquo; ability to understand patients\u0026rsquo; thoughts (cognitive) and emotional experiences (emotive) and respond appropriately (behavioural). We focused on the development of medical students\u0026rsquo; clinical empathy during UME with China as a case example. In China\u0026rsquo;s UME system, medical students typically spend the first three years in basic biomedical education, followed by a fourth year focused on preclinical training that includes simulation-based learning and a fifth year dedicated to clinical clerkship. Accredited by the World Federation for Medical Education (WFME), China's UME system follows internationally recognized standards and has also established its own accreditation standards for basic medical education in China (Ministry of Education, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), emphasizing core competencies such as clinical empathy (Working Committee for the Accreditation of Medical Education, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). To examine the developmental trajectory of clinical empathy, this study adopted a qualitative approach. Data were gathered via semistructured interviews with eight fifth-year medical students and observations of 26 clinical skill assessments involving 16 fourth-year students. The study investigated (1) how simulation-based and clinical clerkship contexts shape students' clinical empathy and (2) how clinical empathy develops during the transition from the former to the latter learning context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study adopts a constructivist paradigm, which acknowledges that knowledge and meaning are socially constructed rather than objectively discovered (Rees et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Our interview data reflect participants' socially constructed interpretations of their experiences rather than any \"objective\" or \"factual\" record of events. Through interviews, participants conveyed their perceptions and meaning-making processes shaped by their educational and clinical contexts.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eResearch Settings\u003c/h3\u003e\n\u003cp\u003eThis study was conducted within the context of clinical training for fourth- and fifth-year medical students during UME. After completing two to three years of foundational training in medical school, the students continued their training in hospital settings.\u003c/p\u003e\u003cp\u003eThe fourth-year medical students lived and received preclinical training in the hospital and took part in internships. Before advancing from clerkship to internship in their fifth year, they had to pass an assessment designed to evaluate their proficiency in clinical skills, which was usually administered at the hospital\u0026rsquo;s Clinical Skills Training Center at the end of the fourth year of training. The exam consisted of six stations, each lasting ten minutes, with students completing the full circuit in one hour. The stations covered two physical examination tasks, two history-taking tasks, and two procedural skill tasks. The procedural skills stations required students to demonstrate techniques on simulation models, including mannequins, prosthetic limbs, and silicone tissue blocks. In contrast, the history-taking and physical examination stations involved standardized patients (SPs), trained actors simulating real patient scenarios. Some of the physical examination tasks required students to interact with both SPs and simulation models, such as performing a breast examination on a simulated torso.\u003c/p\u003e\u003cp\u003eFifth-year medical students were required to rotate through various clinical departments over the course of their one-year internship in their final academic year of UME. During each rotation, students worked under the supervision of attending physicians and senior residents, gradually taking on increasing responsibilities in patient care. Their tasks included conducting patient interviews, performing physical examinations, assisting in medical procedures, writing patient records, and participating in case discussions.\u003c/p\u003e\n\u003ch3\u003eParticipant Recruitment\u003c/h3\u003e\n\u003cp\u003eWe conducted semistructured interviews with 8 fifth-year medical students and observed 16 fourth-year medical students. Participants were selected using purposive sampling to ensure that they had direct clinical experience in either simulation-based learning or clerkship rotations. For the interviews, the inclusion criteria were that the student participants had completed at least six months of clinical clerkship and had actively performed clinical tasks during their training. Students who had engaged only in observation without hands-on practice were excluded from the study. The sample size for the interviews was determined on the basis of the principle of data saturation\u0026mdash;that is, interviews continued until no new key themes emerged, ensuring comprehensive coverage of relevant perspectives to maximize the representativeness of the sample and maintain analytical rigor (Saunders et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provide detailed demographic information on the interviews and observation participants.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOverview of Interviewees (N\u0026thinsp;=\u0026thinsp;8).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGrade\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eClerkship Duration\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eClerkship Department\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eInterview Data\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFive-year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c5\"\u003e\u003cp\u003e2023.6-2024.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUndecided\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2024.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u0026thinsp;+\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c5\"\u003e\u003cp\u003e2023.7-2024.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePediatrics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2024.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u0026thinsp;+\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c5\"\u003e\u003cp\u003e2023.7-2024.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOphthalmology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2024.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFive-year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c5\"\u003e\u003cp\u003e2023.4-2024.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eObstetrics and Gynecology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2024.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u0026thinsp;+\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c5\"\u003e\u003cp\u003e2023.7-2024.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOphthalmology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2024.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u0026thinsp;+\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c5\"\u003e\u003cp\u003e2023.7-2024.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePediatrics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2024.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u0026thinsp;+\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c5\"\u003e\u003cp\u003e2023.7-2024.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePediatrics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2024.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFive-year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFifth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c5\"\u003e\u003cp\u003e2023.6-2024.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUndecided\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2024.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOverview of Observed Participants (N\u0026thinsp;=\u0026thinsp;16).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysical\u003c/p\u003e\u003cp\u003eExamination\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedical\u003c/p\u003e\u003cp\u003eHistory Taking\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBasic\u003c/p\u003e\u003cp\u003eProcedures\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003cp\u003eof Observations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e The numbers in rows 3-6 indicate the number of times participants were observed\u003c/p\u003e\u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected from April 2 to May 18, 2024, through two primary methods\u0026mdash;semistructured interviews with fifth-year medical students and nonparticipant observations of fourth-year medical students. These methods were chosen to examine medical students\u0026rsquo; development of empathy from simulation-based learning to clerkship. The interviews focused on the students\u0026rsquo; \u003cstrong\u003ecognitive and emotional empathy\u003c/strong\u003e by exploring their perceptions and experiences, whereas the observations provided insights into their \u003cstrong\u003ebehavioural empathy\u003c/strong\u003e by capturing how they demonstrated empathy in real clinical interactions. While the interviews provided students\u0026rsquo; self-reported reflections on empathy, direct observation enabled researchers to capture how empathy was enacted in real-time clinical interactions. By combining these approaches, this study aimed to investigate not only how students understand and experience empathy but also how they apply it in practice.\u003c/p\u003e\n\u003cp\u003eThe semistructured interviews were designed to explore students\u0026rsquo; experiences with simulators and patients in both simulation-based learning and clinical clerkship and how their empathy developed throughout their training. The interviews started with general questions about the students\u0026rsquo; clinical internship experiences, including their departmental rotations, responsibilities, and workload. The focus then shifted to their interactions with patients, prompting reflections on significant encounters that shaped their understanding of patients\u0026rsquo; thoughts, emotions, and needs. Next, the interviews explored their experiences during simulation-based learning, asking students to recall specific training scenarios and reflect on how these experiences prepared them for real patient interactions. Emphasis was placed on how simulation helped them develop communication skills, recognize emotional cues, and navigate patient concerns. Finally, students compared the simulation-based learning with real patient encounters, evaluating how practising on simulators influenced their ability to empathize with actual patients. This section aimed to assess the transferability of empathy-related skills from simulation to clinical practice, highlighting both benefits and limitations.\u003c/p\u003e\n\u003cp\u003eNonparticipant observation was conducted on May 18\u003csup\u003eth\u003c/sup\u003e, 2024, during a clinical skills examination at Peking University People\u0026apos;s Hospital. The examination consisted of six stations involving tasks such as physical examinations, history-taking, and basic clinical procedures. Students interacted with both SPs and simulation devices. The observations focused on how the students communicated with the simulators and SPs, demonstrated empathy through verbal and nonverbal behaviours, and responded to patient concerns. Particular attention was paid to signs of active listening, a compassionate tone, patient-centred questioning, and the ability to recognize and address patients\u0026rsquo; emotions.\u003c/p\u003e\n\u003ch2\u003eData Analysis\u003c/h2\u003e\n\u003cp\u003eWe employed thematic analysis following Braun and Clarke\u0026rsquo;s (2006) framework. The analysis process included the following steps:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eBecoming Familiar with the Data:\u0026nbsp;\u003c/strong\u003eThe research team began by reading and rereading the transcripts and observational data, focusing particularly on emotional responses and expressions of empathy in both simulated and clinical settings.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGenerating Initial Coding:\u0026nbsp;\u003c/strong\u003eWe coded the transcripts line by line to identify recurring features related to empathy development from simulated learning to clerkship. Initial codes such as \u0026ldquo;performing a play\u0026rdquo; and \u0026ldquo;emotional engagement\u0026rdquo; were identified.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSearching for Themes\u003c/strong\u003e: After generating initial codes, we grouped related codes into potential themes. For example, we combined the codes \u0026ldquo;performing a play\u0026rdquo; and \u0026ldquo;emotional engagement\u0026rdquo; into the single overarching theme of \u0026ldquo;emotional activation. \u0026rdquo;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReviewing the Themes\u003c/strong\u003e: Through team discussion and further data review, we ensured that each theme was well supported by the data and that the themes accurately reflected the core aspects of empathy development. For example, for the theme \u0026ldquo;emotional activation\u0026rdquo;, we clarified how students\u0026rsquo; emotional involvement transitioned from \u0026ldquo;play-acting\u0026rdquo; in simulated settings to deeper emotional engagement in complex clerkship environments.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDefining and Naming the Themes\u003c/strong\u003e: We clearly defined and named the themes. These definitions and names were refined to ensure that each theme clearly reflected the data and the research questions, effectively capturing the evolution of empathy in the medical students. For example, we identified the following two kinds of performances during simulated-based learning: \u0026ldquo;one-person show\u0026rdquo; and \u0026ldquo;two-person show\u0026rdquo;.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;\u003cstrong\u003eOrganizing the Themes\u003c/strong\u003e: In the final report, we presented the definitions and data extracts for each theme, providing a clear narrative that linked the findings to the research question and built a conceptual framework to organize all the key themes. We also incorporated member checking by sharing the preliminary findings with two participants to confirm the accuracy and relevance of our interpretations. Their feedback was used to refine and enhance the final report.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWe used NVivo software 12 (QSR Internation Ltd, Version 12, 2018) to manage and organize the qualitative data. Thematic saturation was achieved when no new themes emerged from the data.\u003c/p\u003e\n\u003ch2\u003eReflexivity\u003c/h2\u003e\n\u003cp\u003eThe research team consists of scholars with diverse academic backgrounds relevant to medical education and qualitative research. The first and second authors are graduate students specializing in professional health education, with backgrounds in psychology and\u0026nbsp;education, respectively. Both authors have received formal training in qualitative research methods and have independently conducted qualitative studies. The corresponding author, an expert in the field of medical education, provided guidance and oversight throughout the research process.\u003c/p\u003e\n\u003cp\u003eThis multidisciplinary perspective enabled the team to critically analyse the data, incorporating both theoretical and experiential insights. The constructivist approach adopted in this study acknowledges that knowledge is socially constructed and shaped by researchers\u0026apos; positionalities. To enhance the credibility of the findings, the team engaged in reflexivity, continuously reflecting on their roles, assumptions, and potential biases during data analysis and interpretation.\u003c/p\u003e\n\u003ch2\u003eEthical Approval\u003c/h2\u003e\n\u003cp\u003eEthical approval (IRB00001052-20069) was obtained from the Institutional Review Board of Peking University. All participants provided informed consent to participate. The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified the following three key themes to compare how the medical students in the sample expressed empathy towards medical simulators in simulated settings and patients during clerkship: (1)\u0026nbsp;emotional activation, (2)\u0026nbsp;procedural thinking,\u0026nbsp;and\u0026nbsp;(3) perspective on patients. In addition, we constructed a conceptual framework to organize these themes, as shown in Figure 1, which are\u0026nbsp;described in\u0026nbsp;more detail as follows:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eemotional activation: from \u0026ldquo;play-acting\u0026rdquo; in the simulated environment to emotional engagement in the complex clerkship;\u003c/li\u003e\n \u003cli\u003eprocedural thinking: from results-oriented process thinking to understanding differences among patients; and\u003c/li\u003e\n \u003cli\u003eperspectives on patients: from a task-oriented localized view to empathetic care for patients as a whole.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e[Insert Figure 1]\u003c/p\u003e\n\u003ch2\u003eEmotional Activation: From \u0026ldquo;Play-Acting\u0026rdquo; in the Simulated Environment to Emotional Engagement in the Complex Clerkship\u003c/h2\u003e\n\u003cp\u003eAlthough simulation-based learning aims to recreate clinical settings as realistically as possible to offer learning opportunities, the simulated environment cannot fully replicate real clinical situations. During these exercises, students followed a procedural routine. When they were interviewed about simulation learning and simulation-based assessments, every participant used the term \u0026ldquo;performance.\u0026rdquo; For example,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Our teacher told us to care for patients, so we incorporated that into our performance, something like that\u0026quot;\u003c/em\u003e (1-2).\u0026rdquo;\u0026nbsp;\u003cem\u003e\u0026quot;When doing it on a model, it doesn\u0026rsquo;t feel very real, like I\u0026apos;m acting\u0026quot;\u003c/em\u003e (1-5).\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWhen working on a dummy during simulation, we just perform the action of covering them with a blanket because that\u0026rsquo;s required but not to protect their privacy or prevent them from getting cold as doctors will do on real patients\u003c/em\u003e\u0026rdquo; (1-2).\u003c/p\u003e\n\u003cp\u003eMoreover, because actions performed in the simulations did not have real clinical consequences, students often focused more on completing the exam and meeting assessment criteria, reinforcing a procedural mindset. For example, when examining a prosthetic arm, as the students knew that the arm would not feel pain, they did not develop empathy for it. However, in an attempt to meet the humanistic care requirements of the exam, they behaved as if they understood the feelings of the patients. They chose different ways to demonstrate this understanding. Some students reported directly to the examiner in the third person (e.g., in 2-5, \u0026quot;\u003cem\u003eI told the patient that the wound might hurt and advised her to rest\u003c/em\u003e\u0026quot;). Others spoke to the simulated patient in the first person as if they were talking to a real patient (e.g., in 2-3, \u0026quot;\u003cem\u003eYour wound is healing well, with no discharge or complications\u003c/em\u003e\u0026quot;). Students\u0026rsquo; performance level also varied. For example, during an emergency simulation with a dummy, some students showed tension by anxiously shouting \u0026quot;Zhang, Zhang, what happened?\u0026quot; while patting the dummy\u0026apos;s shoulder (2-2). Others expressed tension with repetitive phrases such as \u0026quot;Sir, sir, are you okay?,\u0026quot; while some students calmly asked \u0026quot;Sir, can you hear me?\u0026quot; (2-6).\u003c/p\u003e\n\u003cp\u003eHowever, the medical students commonly recalled feeling nervous during their first clinical procedures on real patients. Although the students in their fifth-year clerkship phase had typically performed only low-risk procedures, many of them had practised these procedures during simulation-based learning. The nervousness stemmed mainly from the fear of harming the patient or causing a direct adverse outcome. Examples of this fear included the following: \u0026quot;\u003cem\u003eThe C-section incision in obstetrics is large, and I was afraid of hurting her\u0026quot; (1-2); \u0026quot;Afraid of damaging the birth canal\u003c/em\u003e\u0026quot; (1-4); \u0026quot;\u003cem\u003eSometimes when clamping cotton balls, I\u0026apos;m afraid I might accidentally hurt the patient\u0026apos;s wound\u003c/em\u003e\u0026quot; (1-5); \u0026quot;\u003cem\u003eI hadn\u0026rsquo;t operated on a real person before, and I was afraid it would hurt them a lot\u003c/em\u003e\u0026quot; (1-6); and \u0026quot;\u003cem\u003eI had never tried it on a real person\u003c/em\u003e\u0026quot; (1-3). There was also concern about breaking the sterile field, potentially harming the patient indirectly, as follows: \u0026quot;\u003cem\u003eI was afraid of contaminating the sterile field\u003c/em\u003e\u0026quot; (1-2), \u0026quot;\u003cem\u003eI\u0026apos;m most worried about contamination\u003c/em\u003e\u0026quot; (1-6), and \u0026quot;\u003cem\u003eI didn\u0026rsquo;t dare move, didn\u0026rsquo;t dare touch... the most important thing is you can\u0026rsquo;t touch anything, or you\u0026rsquo;d have to stop because you\u0026apos;d have violated the sterile field\u003c/em\u003e\u0026quot; (1-6).\u003c/p\u003e\n\u003cp\u003eUnlike in simulation practice, where there are no real clinical consequences, this anxiety is common in real clinical settings but does not usually hinder students\u0026rsquo; performance, and it typically fades after students perform a few procedures on real patients.\u003c/p\u003e\n\u003ch2\u003eProcedural Thinking: From Outcome-Oriented Process Thinking to Understanding Differences among Patients\u003c/h2\u003e\n\u003cp\u003eAs the medical school required the students to demonstrate empathetic care, students often performed to show that they understood the situation or symptoms that simulated patients were experiencing. We identified two kinds of performance, \u0026quot;one-person show\u0026quot; and \u0026quot;two-person show\u0026quot;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn \u0026quot;one-person shows\u0026quot;\u003c/strong\u003e, the students worked with simulated dummies, prosthetics, or silicone models; these devices did not provide feedback, and the students needed to follow a set procedure to show their clinical skills. In these circumstances, we observed that students inevitably \u0026quot;forgot steps\u0026quot;. During an emergency resuscitation exam, all four students correctly answered that the patient\u0026rsquo;s head should be tilted back, but when faced with a dummy whose head was elevated by a pillow placed there by the examiner, only one student (2-8) removed the pillow. During wound dressing exams, students used contaminated forceps to pick up sterile cotton balls (2-3), touched sterile cotton balls with their fingers (2-4), and placed scissors on a sterile tray (2-16), failing to adhere to sterile techniques. However, when asked about wound dressing and suture removal in real clinical settings, all the interviewees emphasized the importance of \u0026quot;not breaking sterile principles\u0026quot;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn \u0026quot;two-person shows\u0026quot;\u003c/strong\u003e, standardized patients (SPs) could respond to students\u0026apos; questions and actions during physical exams and medical history interviews. In these cases, the students could pick up \u0026quot;exam clues\u0026quot; from the SPs\u0026rsquo; responses and adjust their answers accordingly. The forgetting that occurred in the one-person show was less common in the two-person show. During the observations, the same medical student at the same exam station, requiring both a simulated chest organ and interaction with an SP, asked the SP questions such as \u003cem\u003e\u0026quot;Does this hurt?\u0026quot;\u003c/em\u003e and said, \u003cem\u003e\u0026quot;Please try to relax\u0026quot;\u003c/em\u003e while examining the SP, but when examining the simulated organ, the student proceeded without interacting, simply reporting the results as follows: \u003cem\u003e\u0026quot;No swelling in the breast, some discharge from the right nipple\u0026quot;\u0026nbsp;\u003c/em\u003e(2-9). Similar situations were observed with other students (2-15). As one student explained, \u003cem\u003e\u0026quot;I needed to do an axillary dissection, and for that, the patient\u0026apos;s arm must be positioned a certain way, but my model didn\u0026rsquo;t have an arm, so I completely forgot to position it and just proceeded with the operation\u0026quot;\u003c/em\u003e (1-2). Other interviewees shared similar experiences, such as \u003cem\u003e\u0026quot;It feels more real and flows better when working with a real person than on a model\u0026quot;\u003c/em\u003e (1-5).\u003c/p\u003e\n\u003cp\u003eUnlike simulation-based learning, clerkship required students to face actual patients rather than standardized models and patients. Each patient was unique, differing significantly from those in simulated scenarios. Consequently, the students had to adapt their procedures accordingly.\u003c/p\u003e\n\u003cp\u003eFirst, there was a difference between equipment and real people. Procedures on models were more rigid because the equipment could not fully replicate the complexity of real-life situations. For example, during urinary catheterization, the catheter stayed fixed once inserted into a model, but when the procedure was performed on a male patient, it could bounce back if it was not fully inserted (1-5). The models were standardized, but in real patients, factors such as subcutaneous fat (1-2), tissue growth (1-1), and pain tolerance (1-6) differed, requiring adjustments in the procedure. For example, the students might need to double check whether the catheter is inserted correctly. Clinical complexities could include issues such as tightly tied suture ends that were difficult to remove, causing the patient to cry out in pain (1-2), or a tightly adhered adhesive causing discomfort, requiring the student to slow down and reassure the patient (1-6). Although the assessment requirements were well defined in the simulations, in real clinical practice, students needed to interpret imaging data before performing a procedure, such as determining the location of pleural effusion for a thoracentesis, with one student stating that \u003cem\u003e\u0026quot;The models are too rigid for this\u0026quot;\u003c/em\u003e (1-4).\u003c/p\u003e\n\u003cp\u003eFurthermore, in clinical settings, students needed to account for patient preferences. Patients were no longer passive objects of operation but could ask questions, and students could not predict what they would ask, leading to unexpected scenarios. For example, while performing suturing on a thyroidectomy patient, since the wound was on the neck\u0026mdash;a visible area\u0026mdash;students needed to perform subcutaneous suturing, which was a more difficult technique than what they had learned (1-8). During a lumbar puncture, a patient might express discomfort, prompting the student to stop and seek help from their supervisor (1-1). Although the students had learned how to take medical histories, in real clinical settings, patients\u0026rsquo; responses might not follow the logical sequence from class. As one student noted, \u003cem\u003e\u0026quot;They jump from one topic to another, and suddenly, you don\u0026rsquo;t know what to ask anymore\u0026quot;\u0026nbsp;\u003c/em\u003e(1-2).\u003c/p\u003e\n\u003cp\u003eStudents could also learn from their clinical instructor, especially when they entered the clinical setting at the beginning, knowing little about how to comfort patients and provide care. As one student stated,\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eMy instructor will tell me to consider patients\u0026rsquo; status and show me how to do this. Sometimes, patients express concerns about being unable to afford medical expenses. The instructor will keenly pick up these details and introduce them to medications that qualify for higher medical reimbursement. This way, patients can feel less worried about the financial burden. Then\u003c/em\u003e\u003cem\u003e,\u003c/em\u003e\u003cem\u003e\u0026nbsp;I will know how to deal with similar circumstances\u0026rdquo;\u003c/em\u003e (1-2).\u003c/p\u003e\n\u003ch2\u003ePerspectives on Patients: From a Task-oriented Localized View to Empathetic Care for Patients as a Whole\u003c/h2\u003e\n\u003cp\u003eIn clinical practice, the medical students often shifted between focusing on \u0026quot;local\u0026quot; and \u0026quot;global\u0026quot; perspectives while treating patients. Clinical procedures were divided into steps, with different tasks requiring different perspectives.\u003c/p\u003e\n\u003cp\u003eIn the operating room, only the area being operated on was exposed, with the rest of the patient\u0026rsquo;s body covered by sterile drapes. The procedure itself was performed on localized tissue, and students adopted a highly focused, localized perspective. For example, as one student noted, \u003cem\u003e\u0026quot;You only see the exposed part needed for the surgery, which could be just a section of the abdomen, and at that moment, you\u0026rsquo;re really only seeing tissue, not the whole person\u0026quot;\u003c/em\u003e (1-5). This localized perspective became more prominent during processes such as cutting and separating tissues as follows: \u003cem\u003e\u0026quot;When I saw the thyroid gland being cut away, I felt an even stronger sense of focusing on just that small area\u0026quot;\u003c/em\u003e (1-7). This is a process of \u0026quot;targeting the problem\u0026rdquo;, where a specific lesion is removed, and as a result, other symptoms caused by the lesion also improve (1-8).\u003c/p\u003e\n\u003cp\u003eHowever, once the surgery was complete and suturing began, the students shifted to a more global perspective, focusing on restoring the patient\u0026rsquo;s body to its original state as follows: \u003cem\u003e\u0026quot;As I sutured each layer back together, I gained a sense of wholeness\u0026quot;\u0026nbsp;\u003c/em\u003e(1-7). Suturing was seen as a way to return the patient to as close to normal as possible. Thus, \u003cem\u003e\u0026quot;The goal is to help the patient\u0026rsquo;s overall condition recover as much as possible\u0026quot;\u003c/em\u003e (1-7).\u003c/p\u003e\n\u003cp\u003eHow did students switch between focusing on the local and the global? One student offered the following analogy: \u003cem\u003e\u0026quot;It\u0026rsquo;s like being familiar with a school\u0026mdash;you know exactly where you are at any given moment while walking from your dorm to the cafeteria, but in the moment, you\u0026rsquo;re focused on walking and watching the people and cars around you\u0026quot;\u003c/em\u003e (1-8). During local procedural tasks, their attention was turned to the patient\u0026rsquo;s tissues and organs. For medical students with limited experience, even this local information could be overwhelming, making it difficult to focus on anything else. Although they understood that the patient was a whole person, during the procedure, they tended to \u0026quot;not think about it too much\u0026quot; and \u0026quot;empty their minds\u0026quot; (1-8).\u003c/p\u003e\n\u003cp\u003eAdditionally, patient feedback reminded the students to view the patients as whole persons rather than just body parts. All the respondents noted that when changing bandages or removing sutures in the ward, it was impossible to treat the patient as a disjointed part. Simulation equipment may have mimicked only specific body parts, but in real clinical practice, the surrounding environment and patient reactions also influenced the students. For example, while a medical student was changing a dressing on the inpatient ward, a patient might complain of pain, and nearby patients might watch nervously (1-2). Furthermore, the protocols of the clinical environment encouraged students to view patients holistically. While students were suturing in the operating room, external cues such as hearing the patient\u0026rsquo;s heart rate monitor or monitoring equipment might remind them of the patient\u0026rsquo;s overall condition. During simulations, however, multiple students might work on a model at the same time, diminishing the sense of a real clinical environment (1-8). In simulations, students focused solely on the technical task, but with real patients, considerations such as presurgery evaluations and postop care also made students aware of the need for aesthetic suturing to improve patient outcomes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBoth simulation-based learning and clinical learning have unique advantages in developing clinical empathy among medical students, and these two items are complementary. Simulation learning offers a safe practice environment for medical students to familiarize themselves with clinical procedures, such as mastering patient interview techniques. Additionally, by repeatedly practising empathy in simulated scenarios using standardized patients and models, students develop a deeper appreciation for patient-centred care and the importance of empathetic interactions in clinical practice. During clinical clerkship, medical students cultivate empathy by directly interacting with patients, actively listening to their concerns, and gaining a deeper understanding of their needs and emotional experiences. Experiencing real-life patient encounters shows students the human impact of medical care, fostering emotional connection and perspective-taking. Additionally, as they recognize their responsibility for patient outcomes, they develop a stronger sense of accountability, which reinforces their ability to empathize with patients and respond with compassion in clinical practice.\u003c/p\u003e\n\u003ch2\u003eSimulation-Based Learning: Standardized Practice in a Safe and Controlled Environment\u003c/h2\u003e\n\u003cp\u003eSimulation learning in medical education provides a safe and controlled environment where students can practice and improve without risk. This environment helps reduce students\u0026rsquo; psychological pressure, allowing them to focus on learning essential clinical and empathy skills. According to situational learning theory, the learning environment significantly influences learning outcomes. The simulated clinical environment aids students in applying their knowledge and skills during real-world practice (Dawley \u0026amp; Dede, 2014; Lunce, 2006). In this setting, students can freely explore and gradually build confidence in their empathy skills.\u003c/p\u003e\n\u003cp\u003eIn addition, through repeated practice and successful experiences in simulation-based learning, students gradually develop self-efficacy. Bandura\u0026apos;s (1977) theory of self-efficacy states that self-efficacy refers to one\u0026rsquo;s confidence in successfully completing a task. In the low-pressure environment of simulation, students can practice clinical skills repeatedly, gain proficiency and experience success, not only enhancing their self-efficacy but also allowing them to confidently apply these skills when facing real patients.\u003c/p\u003e\n\u003ch2\u003eClinical Clerkship: Professional Development in Real-World, Dynamic Workflows\u003c/h2\u003e\n\u003cp\u003eThe clerkship period, as a critical phase in the professional socialization process of medical students, shapes how they interact with patients, colleagues, and the broader healthcare system (Chandran et al., 2019). In particular, learning in clinical clerkship settings is widely regarded as the \u0026ldquo;gold standard\u0026rdquo; of clinical education for fostering empathy, offering unparalleled advantages (Nyoni et al., 2021; Partner et al., 2022). In modern medical practice, empathy has evolved beyond being merely an emotional response; it is now recognized as an essential professional competency that is systematically and normatively integrated into healthcare processes. This professionalized form of empathy requires medical students to not only understand and respond to patients\u0026rsquo; emotional needs but also incorporate empathy into every stage of clinical decision-making, ensuring the comprehensiveness and personalization of healthcare services. This empathetic process reflects students\u0026rsquo; profound respect and care for patients in professional practice, as well as the implementation of patient-centred care within a framework of institutional support.\u003c/p\u003e\n\u003cp\u003eIn a real clinical environment, medical students receive feedback from patients and health care team members. This feedback goes beyond technical evaluation, also encompassing emotional and attitudinal aspects. Patients\u0026rsquo; real reactions help students better understand the significance and impact of empathy in medical practice. Kolb\u0026rsquo;s (1984) experiential learning theory indicates that feedback obtained through concrete experiences and reflection greatly enhances learning and skill development. By engaging in real-world clinical practice, medical students can accumulate valuable experience and improve their clinical skills, including empathy (Gavigan, 2010; O\u0026rsquo;Neill, 2010).\u003c/p\u003e\n\u003cp\u003eIn addition, clinical instructors play a key role in shaping medical students\u0026rsquo; empathetic abilities, which is consistent with findings from previous studies (Yazdi et al., 2019). By observing and imitating instructors\u0026apos; interactions with patients, students can learn how to apply empathy skills in actual clinical scenarios. Instructors\u0026rsquo; behaviour, methods for handling patients\u0026rsquo; emotions, and caring attitude serve as exemplary models. Close collaboration with instructors enables students to better understand and master the practical application of clinical empathy.\u003c/p\u003e\n\u003ch2\u003eInsights for Clinical Empathy Education in Medical Training\u003c/h2\u003e\n\u003cp\u003eMedical education curricula should integrate both simulation learning and clinical clerkship to ensure that students develop clinical empathy at different stages. Simulation learning usually focused more on building strong foundational skills and empathy techniques, whereas clerkship could prioritize real patient feedback and clinical outcomes to further enhance empathy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the preclinical phase, simulation-based learning is used to develop solid clinical and empathy skills, whereas during the clerkship phase, emphasis is placed on enhancing medical students\u0026rsquo; empathy through feedback from real patients and clinical outcomes. Helping medical students better connect simulation exercises with real clinical scenarios in the simulation learning environment may further aid their understanding of the teaching design\u0026rsquo;s objectives, thereby improving training outcomes. Additionally, though the present study didn\u0026rsquo;t find that empathy declines as students transited into clerkship, it is necessary to emphasize the requirement for medical students\u0026apos; empathic abilities in simulated learning environments (e.g., assigning a higher weight to empathy scores in clinical skills assessments). This approach can help medical students establish the crucial understanding that empathy is vitally important before entering clinical practice. Comparatively, while clinical skills will continue to be honed after entering clinical settings, empathic abilities may become neglected amidst busy clinical work as workload is negatively related to clinical empathy (Chi et al., 2024). Cultivating higher levels of empathic competence and awareness during early training can empower medical students to maintain high-quality empathic care for patients even when confronted with demanding workloads. A recent research also highlights that incorporating medical improvisation into curricula can improve medical students\u0026rsquo; empathy skills (Herber-Valdez et al., 2024). However, the design of such exercises must align with learning aims; otherwise, there may be a disconnect between the exercises and teaching goals (Chan et al., 2024).\u003cem\u003e\u0026nbsp;\u003c/em\u003eAdditionally, considering the limitations of simulation tools, such as insufficient realism and a lack of personalized feedback, establishing a systematic mechanism for reflection and feedback is crucial, as it allows students to engage in continuous self-reflection and improvement through both simulation-based learning and clinical clerkship.\u003c/p\u003e\n\u003cp\u003eConsistent with previous findings\u0026nbsp;(Yazdi et al., 2019), this study\u0026nbsp;revealed\u0026nbsp;that clinical educators play a vital role in students\u0026rsquo; development of clinical empathy. Institutions should strengthen training and support for clinical educators to improve their teaching abilities and increase their empathy, providing students with exemplary clinical role models. During clinical clerkship, clinicians can also offer courses on clinical communication and empathy so that medical students can learn these skills from instructors. For\u0026nbsp;example, a medical school in Germany provides courses on\u0026nbsp;doctor‒patient\u0026nbsp;communication skills during the clerkship phase. A study of this program showed that although the students experienced increased work stress in the clinical environment, their empathy levels did not decline\u0026nbsp;(Roling et al., 2020). Furthermore, teaching medical students communication skills for discussing diseases during internal medicine clerkship can enhance their sense of efficacy in\u0026nbsp;doctor‒patient\u0026nbsp;communication and promote the development of empathy skills\u0026nbsp;(Yuen et al., 2023).\u003c/p\u003e\n\u003ch2\u003eLimitations and future research\u003c/h2\u003e\n\u003cp\u003eFrom the perspective of interaction with patients, the present study provides some evidence to facilitate understanding the development of medical students\u0026apos; empathy across different teaching contexts, but it also has the following limitations. First, our interviews with eight fifth-year medical students were retrospective, asking them to recall their experiences with simulated learning before entering clerkship and their experiences with real patients. We examined the development of and changes in the students\u0026apos; empathy across these two distinct stages. However, subsequent experiences may have influenced the students\u0026apos; perceptions and attitudes during the recall process. Fortunately, we supplemented our data with observations of 16 preclinical fourth-year medical students. Their experiences interacting with simulated patients can be considered less influenced by their clinical experiences. Future research could consider designing a longitudinal study with intensive data collection (e.g., audio diaries), which would reduce the risk of information loss and address concerns about data richness (Morishita et al., 2023). In addition, this design could better capture the dynamic development of medical students\u0026apos; empathy abilities from simulated learning to clinical practice (Balmer et al., 2021).\u003c/p\u003e\n\u003cp\u003eA second limitation of this study is related to our selection of research participants. While we focus on medical students, their limited learning experiences and life experiences mean that their understanding of empathy is still evolving.\u003c/p\u003e\n\u003cp\u003eFinally, in this study, we interviewed only medical students and did not ascertain whether the behaviours and reactions they mentioned were perceived by patients as empathetic or merely superficial emotional expressions. Future research could consider supplementing patient interviews and matching the data from medical students and patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed that medical students\u0026rsquo; clinical empathy exhibited different characteristics in simulation learning and clinical clerkship contexts. In the simulation environment, empathy was more of a performance based on the scenario, whereas in the clinical environment, it was more easily triggered by patients\u0026rsquo; identity traits, evoking a stronger empathetic response from students.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe study was funded by the National Natural Science Foundation of China (Grant Number: 72174013).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eResearchers H.C. and H.W. performed the conception and design of the work. H.Z. conducted data collection, contributed to quantitative data analysis and drafted the first version of the manuscript. Z.S. contributed to interpretation of data and revised the manuscript. All authors contributed to the selection and interpretation of data, drafting and critical revision of the manuscript. All authors read and approved the final manuscript. All authors agreed to be accountable for all aspects related to the manuscript. Haichun Zhou (H.Z.): methodology, data curation, formal analysis, investigation, writing \u0026ndash; original draft (preparation), visualization. Ziyue Shen (Z.S.): conceptualization, formal analysis, writing \u0026ndash; reviewing and editing. Hongbin Wu (H.W.): conceptualization, writing - reviewing and editing, supervision.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBalmer, D. F., Varpio, L., Bennett, D., \u0026amp; Teunissen, P. W. (2021). Longitudinal qualitative research in medical education: Time to conceptualise time. \u003cem\u003eMedical Education\u003c/em\u003e, \u003cem\u003e55\u003c/em\u003e(11), 1253\u0026ndash;1260. https://doi.org/10.1111/medu.14542\u003c/li\u003e\n\u003cli\u003eBandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. \u003cem\u003ePsychological Review\u003c/em\u003e, \u003cem\u003e84\u003c/em\u003e(2), 191\u0026ndash;215. https://doi.org/10.1037/0033-295X.84.2.191\u003c/li\u003e\n\u003cli\u003eBellini, L. M., \u0026amp; Shea, J. A. (2005). Mood Change and Empathy Decline Persist during Three Years of Internal Medicine Training. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e80\u003c/em\u003e(2), 164. https://doi.org/10.1097/00001888-200502000-00013\u003c/li\u003e\n\u003cli\u003eBraun, V., \u0026amp; Clarke, V. (2006). Using thematic analysis in psychology. \u003cem\u003eQualitative Research in Psychology\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(2), 77\u0026ndash;101. https://doi.org/10.1191/1478088706qp063oa\u003c/li\u003e\n\u003cli\u003eBrown, M. E. L., MacLellan, A., Laughey, W., Omer, U., Himmi, G., LeBon, T., \u0026amp; Finn, G. M. (2022). Can stoic training develop medical student empathy and resilience? A mixed-methods study. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(1), 340. https://doi.org/10.1186/s12909-022-03391-x\u003c/li\u003e\n\u003cli\u003eChan, C. A., Windish, D. M., Spak, J. M., \u0026amp; Makansi, N. (2024). State-of-the-art review of medical improvisation curricula to teach health professional learners communication. \u003cem\u003eAdvances in Health Sciences Education\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(3), 1025\u0026ndash;1046. https://doi.org/10.1007/s10459-023-10296-x\u003c/li\u003e\n\u003cli\u003eChandran, L., Iuli, R. J., Strano-Paul, L., \u0026amp; Post, S. G. (2019). Developing \u0026ldquo;a way of being\u0026rdquo;: Deliberate approaches to professional identity formation in medical education. \u003cem\u003eAcademic Psychiatry\u003c/em\u003e, \u003cem\u003e43\u003c/em\u003e, 521\u0026ndash;527. https://doi.org/10.1007/s40596-019-01048-4\u003c/li\u003e\n\u003cli\u003eChi, D., Yu, H., Wang, Y., Du, X., Ma, H., \u0026amp; Zhang, Y. (2024). The role of empathy and self-compassion in the association between workload and burnout in psychiatric professionals. \u003cem\u003eAsian Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e92\u003c/em\u003e, 103888. https://doi.org/10.1016/j.ajp.2023.103888\u003c/li\u003e\n\u003cli\u003eChua, J. Y. X., Ang, E., Lau, S. T. L., \u0026amp; Shorey, S. (2021). Effectiveness of simulation-based interventions at improving empathy among healthcare students: A systematic review and meta-analysis. \u003cem\u003eNurse Education Today\u003c/em\u003e, \u003cem\u003e104\u003c/em\u003e, 105000. https://doi.org/10.1016/j.nedt.2021.105000\u003c/li\u003e\n\u003cli\u003eCosta, P., Magalh\u0026atilde;es, E., \u0026amp; Costa, M. J. (2013). A latent growth model suggests that empathy of medical students does not decline over time. \u003cem\u003eAdvances in Health Sciences Education\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e, 509\u0026ndash;522. https://doi.org/10.1007/s10459-012-9390-z\u003c/li\u003e\n\u003cli\u003eDawley, L., \u0026amp; Dede, C. (2014). Situated learning in virtual worlds and immersive simulations. \u003cem\u003eHandbook of Research on Educational Communications and Technology\u003c/em\u003e, 723\u0026ndash;734. https://doi.org/10.1007/978-1-4614-3185-5_58\u003c/li\u003e\n\u003cli\u003eDubosh, N. M., \u0026amp; Carter, K. (2024). Teaching Trainees Effective Patient Communication Skills in the Clinical Environment: Best Practices under Crisis Conditions. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e99\u003c/em\u003e(4), 370\u0026ndash;373. Scopus. https://doi.org/10.1097/ACM.0000000000005595\u003c/li\u003e\n\u003cli\u003eEbert, R. H. (1992). Flexner\u0026rsquo;s model and the future of medical education. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e67\u003c/em\u003e(11), 737\u0026ndash;742.\u003c/li\u003e\n\u003cli\u003eEkman, E., \u0026amp; Krasner, M. (2016). Empathy in medicine: Neuroscience, education and challenges. \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(2), 164\u0026ndash;173. https://doi.org/10.1080/0142159X.2016.1248925\u003c/li\u003e\n\u003cli\u003eFragkos, K. C., \u0026amp; Crampton, P. E. (2020). The effectiveness of teaching clinical empathy to medical students: A systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e95\u003c/em\u003e(6), 947\u0026ndash;957. https://doi.org/10.1097/ACM.0000000000003058\u003c/li\u003e\n\u003cli\u003eGavigan, L. (2010). Connecting the Classroom with Real-World Experiences through Summer Internships. \u003cem\u003ePeer Review\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(4), 15\u0026ndash;19.\u003c/li\u003e\n\u003cli\u003eHashim, M. J., Khan, M. A., Kieu, A., Alkaabi, F. M. K., Rubaei, F. K. A. A., Alfazari, M. M. K., Alneyadi, M. A. K., Alsaedi, R. H. S., \u0026amp; Govender, R. (2024). Using reflective writing to enhance empathy among medical students. \u003cem\u003eCanadian Medical Education Journal\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(2), 91\u0026ndash;92. https://doi.org/10.36834/cmej.77172\u003c/li\u003e\n\u003cli\u003eHerber-Valdez, C. R., Blow, J. A., Salazar, T. T., Horn, K. V., Herrera, D. G., Lacy, N. L., Beinhoff, L., \u0026amp; de la Rosa, J. M. (2024). The integrated curriculum and student empathy: A longitudinal multi-cohort analysis. \u003cem\u003eAdvances in Health Sciences Education : Theory and Practice\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(4), 1131\u0026ndash;1153. https://doi.org/10.1007/s10459-023-10292-1\u003c/li\u003e\n\u003cli\u003eHojat, M. (2016). \u003cem\u003eEmpathy in health professions education and patient care\u003c/em\u003e (294 📊). https://doi.org/10.1007/978-3-319-27625-0\u003c/li\u003e\n\u003cli\u003eKelm, Z., Womer, J., Walter, J. K., \u0026amp; Feudtner, C. (2014). Interventions to cultivate physician empathy: A systematic review. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1). Scopus. https://doi.org/10.1186/1472-6920-14-219\u003c/li\u003e\n\u003cli\u003eKolb, D. (1984). Experiential Learning: Experience As The Source Of Learning And Development. In \u003cem\u003eJournal of Business Ethics\u003c/em\u003e (Vol. 1).\u003c/li\u003e\n\u003cli\u003eKrishnasamy, C., Ong, S. Y., Loo, M. E., \u0026amp; Thistlethwaite, J. (2019). How does medical education affect empathy and compassion in medical students? A meta-ethnography: BEME Guide No. 57. \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e41\u003c/em\u003e(11), 1220\u0026ndash;1231. https://doi.org/10.1080/0142159X.2019.1630731\u003c/li\u003e\n\u003cli\u003eLunce, L. M. (2006). Simulations: Bringing the benefits of situated learning to the traditional classroom. \u003cem\u003eJournal of Applied Educational Technology\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(1), 37\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eMercer, S. W., \u0026amp; Reynolds, W. J. (2002). Empathy and quality of care. \u003cem\u003eThe British Journal of General Practice: The Journal of the Royal College of General Practitioners\u003c/em\u003e, \u003cem\u003e52 Suppl\u003c/em\u003e(Suppl), S9-12.\u003c/li\u003e\n\u003cli\u003eMinistry of Education. (2020). \u003cem\u003eWCAME awarded WFME recognition status\u003c/em\u003e. http://en.moe.gov.cn/news/press_releases/202006/t20200628_468685.html\u003c/li\u003e\n\u003cli\u003eMorishita, M., Iida, J., \u0026amp; Nishigori, H. (2023). Reconstructing the concept of empathy: An analysis of Japanese doctors\u0026rsquo; narratives of their experiences with illness. \u003cem\u003eAdvances in Health Sciences Education\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(1), 87\u0026ndash;106. https://doi.org/10.1007/s10459-022-10143-5\u003c/li\u003e\n\u003cli\u003eNeumann, M., Edelh\u0026auml;user, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., Haramati, A., \u0026amp; Scheffer, C. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e86\u003c/em\u003e(8), 996\u0026ndash;1009. Scopus. https://doi.org/10.1097/ACM.0b013e318221e615\u003c/li\u003e\n\u003cli\u003eNyoni, C. N., Dyk, L. H.-V., \u0026amp; Botma, Y. (2021). Clinical placement models for undergraduate health professions students: A scoping review. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e, 1\u0026ndash;26. https://doi.org/10.1186/s12909-021-03023-w\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Neill, N. (2010). Internships as a High-Impact Practice: Some Reflections on Quality. \u003cem\u003ePeer Review\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(4), 4\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003ePartner, A., Shiner, N., Hyde, E., \u0026amp; Errett, S. (2022). First year student radiographers\u0026rsquo; perceptions of a one-week simulation-based education package designed to increase clinical placement capacity. \u003cem\u003eRadiography\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(3), 577\u0026ndash;585. https://doi.org/10.1016/j.radi.2022.04.007\u003c/li\u003e\n\u003cli\u003eRees, C. E., Crampton, P. E., \u0026amp; Monrouxe, L. V. (2020). Re-visioning academic medicine through a constructionist lens. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e95\u003c/em\u003e(6), 846\u0026ndash;850.\u003c/li\u003e\n\u003cli\u003eRoling, G., Lutz, G., Edelh\u0026auml;user, F., Hofmann, M., Valk-Draad, M. P., Wack, C., Haramati, A., Tauschel, D., \u0026amp; Scheffer, C. (2020). Empathy, well-being and stressful experiences in the clinical learning environment. \u003cem\u003ePatient Education and Counseling\u003c/em\u003e, \u003cem\u003e103\u003c/em\u003e(11), 2320\u0026ndash;2327. https://doi.org/10.1016/j.pec.2020.04.025\u003c/li\u003e\n\u003cli\u003eSaunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H., \u0026amp; Jinks, C. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization. \u003cem\u003eQuality \u0026amp; Quantity\u003c/em\u003e, \u003cem\u003e52\u003c/em\u003e(4), 1893\u0026ndash;1907. https://doi.org/10.1007/s11135-017-0574-8\u003c/li\u003e\n\u003cli\u003eStepien, K. A., \u0026amp; Baernstein, A. (2006). Educating for empathy\u0026mdash;A review. \u003cem\u003eJOURNAL OF GENERAL INTERNAL MEDICINE\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(5), 524\u0026ndash;530. https://doi.org/10.1111/j.1525-1497.2006.00443.x\u003c/li\u003e\n\u003cli\u003evan Baal, S. T., Verdejo-Garc\u0026iacute;a, A., \u0026amp; Hohwy, J. (2023). Episodic future thinking and compassion reduce non-compliance urges regarding public health guidelines: A randomised controlled trial. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 189. https://doi.org/10.1186/s12889-023-15031-0\u003c/li\u003e\n\u003cli\u003eWorking Committee for the Accreditation of Medical Education. (2022). \u003cem\u003eStandards for basic medical education in China.\u003c/em\u003e https://wcame.meduc.cn/uploads/soft/20230308/Standards%20for%20Basic%20Medical%20Education%20in%20China--the%202022%20Revision.pdf\u003c/li\u003e\n\u003cli\u003eYazdi, N. A., Bigdeli, S., Arabshahi, S. K. S., \u0026amp; Ghaffarifar, S. (2019). The influence of role-modeling on clinical empathy of medical interns: A qualitative study. \u003cem\u003eJournal of Advances in Medical Education \u0026amp; Professionalism\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(1), 35.\u003c/li\u003e\n\u003cli\u003eYuen, J. K., See, C., Cheung, J. T. K., Lum, C. M., Lee, J. S., \u0026amp; Wong, W. T. (2023). Can teaching serious illness communication skills foster multidimensional empathy? A mixed-methods study. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 20. https://doi.org/10.1186/s12909-023-04010-z\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"advances-in-health-sciences-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ahse","sideBox":"Learn more about [Advances in Health Sciences Education](http://link.springer.com/journal/10459)","snPcode":"10459","submissionUrl":"https://submission.nature.com/new-submission/10459/3","title":"Advances in Health Sciences Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Medical students, Clinical empathy, Medical education, Simulation-based learning, Clerkship","lastPublishedDoi":"10.21203/rs.3.rs-6325059/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6325059/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eLittle is known about how simulation-based learning and clinical clerkship\u0026mdash;two key learning contexts\u0026mdash;shape medical students\u0026rsquo; interaction with simulated and actual patients and influence students\u0026rsquo; clinical empathy. This study investigated the development of clinical empathy among medical students from simulation-based learning to clerkship in China.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn a constructivist paradigm, this study employed an exploratory qualitative approach, adhering to the COREQ. Data were collected through semi-structured interviews with eight fifth-year medical students and observations of 26 instances among 16 fourth-year students in a six-station objective structured clinical examination. Thematic analysis was used to analyse the qualitative data.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn simulation-based learning, medical students focused on improving their clinical skills, seldom perceiving simulators as patients they might encounter in clinical settings, and pretended to show empathetic concern as needed. Furthermore, due to the lack of timely simulator feedback, medical students easily overlooked critical steps in clinical procedures. During clerkship, medical students experienced stronger emotional responses. Concern about potentially harming patients made students more cautious in procedural steps. Medical students gradually recognized patients\u0026rsquo; uniqueness, becoming attuned to emotional cues and alleviating patient suffering by improving their clinical skills. Moreover, their perspective on patients shifted, enabling them to see patients as a whole to carry out medical procedures with empathetic concern.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile simulation provides skill training, its procedural nature limits empathy development. Clerkship, in contrast, fosters medical students\u0026rsquo; emotional engagement, individualized thinking, and flexible views of patients.\u003c/p\u003e","manuscriptTitle":"Exploring the Development of Clinical Empathy among Chinese Medical Students: A Transition from Simulation-based Learning to Clerkship","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:20:19","doi":"10.21203/rs.3.rs-6325059/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-12T14:26:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T15:43:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-28T17:47:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100909413734238138111189567117604389543","date":"2025-08-06T18:15:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62347591644117379255596514518847609133","date":"2025-08-05T19:46:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-31T19:38:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-04T00:25:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-04T00:24:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Advances in Health Sciences Education","date":"2025-03-28T05:24:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"advances-in-health-sciences-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ahse","sideBox":"Learn more about [Advances in Health Sciences Education](http://link.springer.com/journal/10459)","snPcode":"10459","submissionUrl":"https://submission.nature.com/new-submission/10459/3","title":"Advances in Health Sciences Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"22218670-9309-4604-b393-d2487ebd274f","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:05:25+00:00","versionOfRecord":{"articleIdentity":"rs-6325059","link":"https://doi.org/10.1007/s10459-025-10497-6","journal":{"identity":"advances-in-health-sciences-education","isVorOnly":false,"title":"Advances in Health Sciences Education"},"publishedOn":"2025-12-22 15:57:15","publishedOnDateReadable":"December 22nd, 2025"},"versionCreatedAt":"2025-08-06 08:20:19","video":"","vorDoi":"10.1007/s10459-025-10497-6","vorDoiUrl":"https://doi.org/10.1007/s10459-025-10497-6","workflowStages":[]},"version":"v1","identity":"rs-6325059","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6325059","identity":"rs-6325059","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}