Table 2 Summary of themes and supporting quotes

Empathy-focused training and development

Empathy-training is delivered through dedicated teaching

We have developed a 2 week Massive Open Online Course on the platform Future Learn, which all students complete in either Year 1 of MBBS4 or Year 2 of MBBS5 as part of their curriculum. The learning objectives are assessed in OSCEs and all students are required to write a short reflection on their experience/learning from the MOOC. (MEL 1)

The course "Developing Clinical Empathy" aims to help students develop an empathic practice that is personal and attuned to their patients. They learn about what empathy is & it's different facets, they consider their own experiences of empathy and reflect on their and they explore verbal and non-verbal cues with the aim of understanding key opportunities for showing empathy in whilst caring clinically for patients. (MEL 1)

in years 1 & 2 small group workshops (preceded by a lecture) that focus on understanding the patient perspective, and experience and communication skills that communicate this to (simulated) patients and look at the therapeutic nature of the consultation. (MEL 2)

There is a 1 h online workbook that outlines why we should be empathetic to our patients, how it differs from sympathy & reassurance, a model of empathy, and several activities designed to encourage students to identify empathetic responses to patient statements… (MEL 5)

There is a clinical empathy programme that runs throughout the foundation year. (MEL 3)

We have introduced longitudinal placements combined with a patient panel for the whole of year 4 specifically with the aim of students developing long term relationships with doctors and particularly patients to build their empathy. (MEL 10)

we are redeveloping the last few months of our 5th year and I would like to see this [empathy] become a focus within that time (as well as in the earlier years of the course that we already have) (MEL 7)

Specific simulated patient encounters to deal with empathy (MEL 16)

initial small group experiential sessions focusing specifically on what empathy is and ways of communicating and acting empathically… (MEL 14)

Empathy-training is integrated into other teaching activities

teaching about empathy as part of clinical communication teaching activities: either about 'general' aspects of clinical communication (such as patient-centred aims of the consultation) or in specific situations (e.g. difficult communication/breaking bad news). (MEL 19)

we discuss empathy and the use of empathetic statements routinely as part of our small group communication skills training. (MEL 20)

Role play with actors focuses strongly on the students' ability to empathise. (MEL 20)

In early years (1 and 2) we speak explicitly about empathy (what is it, how do we demonstrate it, what is the impact on the patient and the consultation) as part of an introduction to communication skills teaching. (MEL 4)

All of the [communication] skills training includes discussion around empathy. (MEL 8)

We have a Social Accountability (Community based placement) where all third year students choose a 4 week placement in local charities/schools/organisations (in areas of higher deprivation) and further development of empathy is a key feature of students reflections. (MEL 8)

Empathy is discussed from the start of Y1 Communication skills—in the Introductory Lecture, where it is defined

MEL 13

Students begin with triad role-play and the techniques for expressing empathy are practised and evaluated within basic clinical scenarios. Midway through Y1 and throughout Y2, Small group communication skills workshops include trained medical role-play actors. MEL 13

Small group experiential communication skills sessions—all sessions (6 sessions in years 4,5,6) include appreciating patient perspective and empathic responding (MEL 22)

Clinical communication skills teaching sessions—simulated consultations in a wide range of contexts—using volunteer patients and actors. Empathy, patient centredness, and 'what matters to you' embedded in all sessions. (MEL 24)

In the Final year, students attended small group teaching with role play on "Challenging Scenarios" and a full day on 'Breaking Bad News". Empathy focused training plays a very important role in these sessions as we refer to models of communication in which empathy is a key skills to use and demonstrate effectively. (MEL 1)

aims and objectives are also threaded throughout the MBBS programme and each small group experiential session that students have includes the objective to "Practise communicating empathy using appropriate verbal and non-verbal skills"

(MEL 1)

In Year 3 this forms part of the GP day each fortnight where students step into role as patients to enhance their empathy

(MEL 2)

There is a compassionate holistic diagnostic detective module that includes elements of empathy and compassion training during years 1 and 2 (MEL 3)

Attending to patient perspective with our patient partner interactions in communication skills teaching in all years

(MEL 21)

Medical humanities SSC y3 which has a range of options to consider empathy and develop this for patients and self-care too. (MEL 21)

Communication Skills are taught from the first few weeks of Year 1. They are practised weekly by each student with simulated patients. Over the course of 8 sessions, they build up their skill. Throughout, the importance of seeking to understand the patient's perspective is emphasised for being as important as the biomedical aspects…They learn how to demonstrate empathy…This is all part of their first semester training in Consultation Skills

(MEL 23)

I would like to treat it as a spiral topic, to be revisited several times to deepen the student's ability to show empathy—rather than a one and done session. (MEL 5)

We have a case based curriculum and one case in year one has a specific focus with learning outcomes around the importance of, and demonstrating empathy. (MEL 10)

Empathic communication is integrated into pretty much all of the communication training, which occurs throughout the course. (MEL 14)

activities where empathy is referred to include the Elective introduction (the communication lead is also the elective lead) and in 1–1 coaching for students referred as having specific identified challenges with this competency. Empathy also comes up as part of case based discussion on the ethics module – e.g. end if life. (MEL 6)

Classroom sessions on empathy are only a modest start point—it is the integration of theory into the day to day workplace that matters. (MEL 6)

It should be integrated in all teaching rather than specific module (MEL 27)

In the early years, we have a lecture delivered by a patient representative on Compassion and this is very much linked to our empathy-focused training but the lead for this session calls it Compassion. (MEL 1)

Personally, I think it needs some of its own space (so students get a handle on specific skills) but also must be fundamentally interwoven with the values and communication behaviours related to patient-centred care—which must be prevalent throughout the whole medical curriculum. (MEL 19)

Empathy is intrinsically taught through other activities

I think it is very difficult to untangle whether the primary aim of a teaching session is to improve empathy – it is taught with other skill and where the emphasis lies depend on who is teaching. (MEL 9)

so I would say we have dedicated training on wellbeing (which helps awareness of emotional labour of care, suffering and compassion), self-awareness (bias, reaction to situations and triggers, choosing response rather than reaction), trauma-aware care, and compassion—all of which contribute to empathy, but we don't specifically badge it as 'empathy training' (MEL 7)

Communication skills teaching for system focused patient consultation and simulation of the acutely ill patient (MEL 11)

There is a mindfulness programme during year 1. (MEL 3)

We have a large cohort of Patients as Educators (in excess of 800) and they work with students throughout the 5 years (teaching and assessment) to understand the impact of illness. (MEL 8)

We do not use the term empathy-focused training but rather emphasise the importance of empathy in patient encounters

(MEL 12)

we don't label anything specifically as 'empathy training' but we include the above [definition of empathy as used by survey] which contribute to this construct (MEL 7)

[Empathy is] taught to med students through the clinical skills teaching (MEL 16)

this [empathy training] is woven throughout the curriculum and is consolidated through repetition across contexts. (MEL 13)

I think that clinical empathy and associated strategies are predominately learnt via role models in practice (the hidden curriculum) (MEL 26)

Assumption that empathy training is included elsewhere

It is a large part of our communication course. It is also a focus of our patient delivered curriculum in neurology and women's health (MEL 9)

We incorporate this into our communication skills offering (MEL 12)

All clinical placements should have inbuilt opportunities to further develop clinical empathy, but I am unsure how much this occurs. (MEL 6)

We have Community Attachment Scheme in Phase 1 (yr1) which focuses on the psychosocial impact of illness. (MEL 8)

I suspect this is provided on an ad hoc basis in a variety of specialties. Is informally being delivered throughout the curriculum. (MEL 17)

In later years empathic communication is integrated into all aspects of the communication sessions, whether explicitly badged as comms or as part of other areas—sexual health course for instance. (MEL 14)

Session in week 1 designed and led by patient group using drama and interactive activities. Regular "Person of the week" throughout year 1 & term 1 of year 2. Interaction with person, students ask questions live. Early clinical exposure in community settings getting to know 3 people (child, adult, older adult) and presenting a holistic picture of their lives and care experiences. (MEL 18)

We don't specifically say "empathy based training" as we are not teaching students to 'learn to sound empathic' as an isolated skill, or thinking about 'one item'. It is—hopefully—integrated. (MEL 6)

There is specific reference to empathy in the Year 1 plenary, and it is almost always discussed in de-brief of SP sessions cross years/programmes. There is more work to be done, as emphasis may well vary by tutor. (MEL 6)

Consultation skills sessions: Active listening, Dealing with difficult consultations, Elements of GI/GU history-taking (as per the UKCCC curriculum wheel including two sets of ILOs in one session), Breaking bad news (in Giving information), Talking with relatives, Shared decision-making, End of Life care (comms skills) (MEL 15)

it seems this will come up in a number of ways, where teaching is small group and considering ethics, shared decision making, patient centredness, etc. The overall badge is "Clinical Communication and Professionalisation". The challenge is to make the importance of empathy more explicit to students. (MEL 6)

I think that forms part of our communication skills programme due to the important impact of this on interacting with patients. (MEL 4)

none of our course is labelled 'clinical empathy' but I think a lot is delivered that would fit that description (MEL 9)

I would put NHS clinicians in [teaching empathy] but I'm not sure if they really focus on this but more on the clinical—depends on the clinician (MEL 25)

Challenges presented in putting empathy on the curriculum

System-based challenges

Large cohorts are sometimes a barrier, as developing empathy can need specific individual work. It relates to the student's individual lens, world view, maturity and experience. And can need intensive 1–1 support where affiliated to, eg, an attitude/values weakness or an specific learning difficulty. (MEL 6)

Scale is a challenge to standardisation for many schools. This is where crucial role modelling occurs, so is an area where input is needed (MEL 6)

More resourcing for 1–1 sessions would be ideal, as developing empathy can be deeply rooted in the individual's own experiences, anxieties, & insight. (MEL 6)

To remain empathic you must feel valued and supported. This extends to post grad therefore system wide role modelling of empathy is needed not just with patients (MEL 24)

More time and effort should be spent in ensuring our future doctors can be empathetic to their patients. (MEL 5)

It would be great to translate it into the clinical environment however that would involve training all the clinicians who are involved in teaching medical students (MEL 25)

This [training] takes time, reflection and input as they [students] mature and accumulate life experience. This is a process that packed curricula don't easily support. (MEL 6)

Student attitude, experience and engagement

Whilst things have improved for empathy/communication, there are still a reasonable proportion of students who perceive these areas as soft and fluffy, and not as important as the hard science. (MEL 5)

Students with learning difficulties can have particular challenges relating to others, which may need specialist support (Asperger's being one example). This is important, but resource intensive (MEL 6)

Staff and faculty attitudes and experience

Development of empathy I think needs to be positioned as a life-long process, not something we "teach in this session"

MEL 6

Empathy cannot be taught but is nurtured and grows over time. (MEL 11)

The value (wanting to understand other perspectives) should drive the behaviour. We need to shift from an assessment led approach ('what to I need to say in the OSCE') to a values based approach from day 1 ('what sort of doctor do I want to be and what do I need to do to get there'). (MEL 6)

Also we need to recognise that it is developing the value that is paramount (not students 'learning what to say/do' at surface level). This takes time, reflection and input as they mature and accumulate life experience. This is a process that packed curricula don't easily support. (MEL 6)

The simulated patient sessions cross-years pick this up [empathy], but improvements are needed in consistency of tutor approach. SP sessions taking place in GP practices, e.g., rely on large numbers of clinical colleagues whose approaches/focus may differ (MEL 6)

Personally, I wouldn't feel it would be appropriate to routinely use research measures of empathy in medical school teaching and assessment activities. (MEL 19)

empathy is not disaggregated from other skills (and, I would argue, is very difficult to either teach or examine in isolation). (MEL 9)

I do a lot of exploring empathy in my interviews but I'm not sure it happens in all colleges (MEL 9)