Communicative empathy in medical students: between self-perception and the perception of othersABSTRACT
Purpose To compare the level of empathy reported by medical students to that perceived by evaluators during simulated medical consultations.
Methods This was a cross-sectional observational study conducted with 41 medical students. To assess self-perceived empathy, the Empathy Inventory (EI) was used—a 40-item self-report protocol that evaluates empathy based on four factors: Affective Sensitivity (AS), Altruism (AL), Perspective Taking (PT), and Interpersonal Flexibility (IF). To assess empathy from the perspective of others, simulated consultations were conducted in which students performed medical appointments with professional actors. The simulations were video-recorded and evaluated by external judges who were instructed to respond to an adapted version of the CARE Scale (Consultation and Relational Empathy).
Results Regarding EI scores, the sample showed higher mean scores, respectively, for the following factors: Affective Sensitivity, Altruism, Interpersonal Flexibility, and Perspective Taking. The CARE scale showed a moderate overall mean among the three evaluators. The emotions most frequently identified were fear, sadness, and doubt. No correlation was found between EI and CARE scores. Good internal consistency was observed among the evaluators.
Conclusion The study showed that although medical students report higher levels of empathy, this skill is not consistently manifested in simulated practice. The absence of correlation between self-reported empathy and observer-rated empathy suggests a possible gap between internal perception and the observable expression of empathy.
Keywords:
Emotions; Nonverbal communication; Empathy; Health communication; Humanization of assistance
RESUMO
Objetivo Verificar os níveis de empatia relatados por estudantes de Medicina e sua relação com a empatia percebida por avaliadores durante simulações de atendimento médico.
Métodos Estudo observacional com delineamento transversal, realizado com 41 estudantes de Medicina. Para avaliar a habilidade de empatia autopercebida, foi utilizado o Inventário de Empatia, protocolo de autopercepção com 40 itens que avalia a empatia a partir de quatro fatores: Sensibilidade Afetiva, Altruísmo, Tomada de Perspectiva e Flexibilidade Interpessoal. Para avaliar a habilidade de empatia sob a perspectiva do outro, foram realizadas simulações de atendimento nas quais os estudantes simularam um atendimento médico com atores profissionais. As simulações foram registradas em vídeo e avaliadas por juízes externos que foram orientados para responder à escala Consultation and Relational Empathy (CARE) de forma adaptada.
Resultados Em relação à pontuação do Inventário de Empatia, a amostra apresentou maiores médias nos fatores, respectivamente de: Sensibilidade Afetiva, Altruísmo, Flexibilidade Interpessoal e Tomada de Perspectiva. A escala CARE apresentou média geral moderada entre os três avaliadores. As emoções mais identificadas foram medo, tristeza e dúvida. Não houve correlação entre a pontuação do Inventário de Empatia e da escala CARE. Houve boa consistência interna entre os avaliadores.
Conclusão Embora os estudantes de Medicina relatem maiores níveis de empatia, essa habilidade não se manifesta de forma consistente nas práticas simuladas. A ausência de correlação entre a empatia autorrelatada e a avaliada por observadores sugere uma possível lacuna entre a percepção interna e a expressão observável da empatia.
Palavras-chave:
Emoções; Comunicação não verbal; Empatia; Comunicação em saúde; Assistência humanizada à saúde
INTRODUCTION
Communication is an essential skill for establishing healthy interpersonal relationships and promoting effective interactions in both personal and professional settings. During healthcare, communication between the healthcare professional and the patient is a central element in the quality of care and in establishing a therapeutic bond, a crucial aspect for treatment adherence. In this context, this competence is important not only for the technical mastery of verbal language in therapeutic practice, but also for the ability to establish human connections based on respect, active listening, and empathy(1).
Empathy, in this context, is configured as a skill that directly contributes to strengthening interpersonal relationships and patient satisfaction with the care received(2). This aptitude involves affective and cognitive processes, including the ability to recognize and understand the feelings and perspectives of others, as well as to respond appropriately to these emotional states(3). Empathy is understood in the literature as a phenomenon with different dimensions(4). The individual can express this skill in various ways. Depending on the context, it can be recognized as emotional empathy or cognitive empathy. Each of these types of empathy is characterized by its own communicative behavior and is associated with specific factors.
Communicative empathy is an interactional perspective based on the use of verbal and nonverbal communicational aspects as a form of emotional perception and assertive expression in communication(5). Through knowledge and practice of verbal and nonverbal manifestations associated with the emotional state of the other during an interaction, the subject can demonstrate a greater capacity for perceiving feelings, intentions, and needs through active listening. Then express themselves effectively in words, voice, gestures, posture, and other expressive components of communication(6,7). In this sense, it is important that the perceived and demonstrated communication be carried out consciously and coherently, so that this skill can be an effective strategy used in various contexts(8).
The perception of empathy can occur from different perspectives: through self-perception and through the perception of others. When the subject identifies aspects inherent to this process within themselves, they understand their communicative attitude positively during their daily interactions. The perception of empathy by others occurs through the impact of their expression on their interlocutor. When this interaction happens assertively, both subjects recognize empathic traits through verbal and nonverbal channels, and there is a connection of feelings and needs. However, the degree of self-perception of the communicative aspects of empathy is not always consistent with its expression. This can be seen when the subject understands themselves as an empathetic communicator, although they do not demonstrate communicative attitudes consistent with this perception in their practice(9).
In the various undergraduate courses for training professionals in the health field, particularly in Medicine, the development of communicative empathy constitutes one of the challenges faced by educational institutions, since this skill refers to relational and not technical aspects, which are the most valued by students in this area. The development of empathy requires practical experiences that stimulate self-reflection and sensitivity to the emotional demands of others(10,11).
Given this scenario, it becomes relevant to investigate the correspondence between the self-perceived communicative empathy of future physicians and the observation of this skill by external evaluators in simulated care situations, so that this knowledge can be used to raise awareness of the importance of using empathy more consciously and effectively in different contexts during healthcare delivery.
Thus, this study aimed to verify the levels of empathy reported by medical students and their relationship with the empathy perceived by evaluators during medical care simulations.
METHODS
Participants
Observational study with a cross-sectional design, conducted in the Graduate Program in Rehabilitation Sciences at the Federal University of Health Sciences of Porto Alegre - PPG-CR/UFCSPA, approved by the Research Ethics Committee of the institution, under approval number 5.204.872.
Students enrolled in the first or second year of medical school, of both sexes, aged between 18 and 30 years, were invited to participate in the research. The inclusion of students in their first and second years aimed to observe empathic skills in their initial stages. This period is less influenced by institutional practices and already consolidated clinical protocols, in order to favor an understanding of the relationship between self-perception and the initial expression of empathy. The sample was constituted by convenience, based on in-person dissemination in the classroom and digitally, with the sharing of banners in students' social media groups. The duration of this initial phase was approximately six months. Initially, participants who expressed interest in joining the study signed the Informed Consent Form and answered the sample characterization questionnaire.
Sample size calculation was performed based on correlation analysis between scores on the Empathy Inventory (EI) and the Consultation and Relational Empathy (CARE) scale, considering a significance level of 5% and a statistical power of 90%, according to parameters described in the literature for studies with a similar design(11). The estimated minimum sample size was 38 participants. For an expected correlation of r = 0.50, an approximate margin of error of 0.235 was calculated for the 95% confidence interval.
Materials and procedures
To assess self-perceived empathy ability, the Empathy Inventory (EI) was used, a self-perception protocol with 40 items that assesses empathy based on four factors: Perspective Taking (PT), Interpersonal Flexibility (IF), Altruism (AL), and Affective Sensitivity (AS) (Annex 1). The EI is a protocol developed in Brazil, with the aim of offering a psychometric instrument to assess different dimensions of empathy in educational, clinical, and research contexts. It addresses empathy from the perspective of cognitive components (ability to understand the other) and affective components (ability to share and respond to the emotions of the other). The Perspective Taking factor refers to the most widespread empathic behavior among common knowledge. It is the ability to put oneself in another's place and understand their point of view. The Interpersonal Flexibility factor relates to the ability to maintain positive and flexible attitudes in situations of conflict or difference of opinion. The Altruism factor is linked to the tendency to prioritize the well-being of others, even at the expense of one's own interests, and the Affective Sensitivity factor is associated with the ability to perceive and respond sensitively to the emotions of others(12).
The score for each factor of the EI was obtained by calculating the arithmetic mean of the corresponding items, respecting the specific composition of each factor and applying the reverse calculation to the formulated items, according to the instructions of the instrument's authors. Higher values indicate greater self-perceived empathy in that domain.
To assess empathy skills from the perspective of another, simulated patient care scenarios were conducted in which students were instructed to act, in a simulated manner, as physicians in consultations with professional actors representing potential patients. Students were instructed to conduct the consultations as closely as possible to clinical reality, in situations involving initial contact with patients with specific healthcare needs. The objective of this stage was to evaluate the students' communicative and empathic performance in situations involving decision-making based on a diagnosis of serious illness reported by patients. The simulated patient care scenarios were based on studies that demonstrated the effectiveness of this approach as an efficient strategy for practically evaluating and training communication and empathy skills(9,13,14).
Medical care simulations were conducted individually, in a private setting, and recorded on video. Participants were informed that it was a simulation, without prior access to the case. The actors were guided by a pre-structured script adapted to the context of a medical consultation, in which they portrayed emotional reactions associated with grief upon receiving a diagnosis of a serious illness. The interactions focused on observing the students' communicative attitudes, with an emphasis on empathy, active listening, and assertive expression.
The recordings of these simulations were evaluated by three speech-language pathologist judges with expertise in the area of voice and communication, trained in the use of the Consultation and Relational Empathy (CARE) scale and instructed to put themselves in the patient's perspective when watching the video recordings to judge the empathic behaviors manifested during the interaction, based on the items of the scale.
The CARE scale consists of ten items and, in its original format, aims to assess the patient's perception of the empathy demonstrated by the healthcare professional during a consultation(13). It is a widely used instrument in healthcare assessment contexts, as it encompasses aspects related to active listening, understanding, support, therapeutic bond, and empathy in clinical interaction. Each item on the scale is scored from 1 to 5, where 1 corresponds to a "poor" rating and 5 to an "excellent" rating. The "not applicable" option was treated as missing data and was not included in the calculation of the total score. The total CARE score was obtained by adding the scores of the valid items, resulting in values ranging from 10 to 50 points, with higher scores indicating greater perceived empathy. For the analyses, the individual scores assigned by each evaluator were considered, as well as the overall average among the evaluators (Annex 2).
Although the CARE scale was originally developed to assess empathy from the patient's perspective in real clinical consultations, in this study it was used as an observational instrument, with the aim of measuring the communicative empathy expressed by students during care simulations.
The choice of CARE was based on the fact that its items assess observable communicative aspects, such as active listening, demonstration of understanding, emotional support, bonding, and shared decision-making, which can be identified by trained observers in clinical simulation contexts. It is important to note that this application represents an adaptation of the instrument's original use, not intended to replace the assessment of the real patient, but rather to operationalize the perception of empathy based on observable verbal and nonverbal communicative behaviors. Therefore, the results obtained through the CARE scale should be interpreted as a measure of communicative empathy perceived by external observers in the specific context of clinical simulations(9,13).
Following the simulation, the research participants completed a self-assessment questionnaire about their communicative performance during this interaction. The questionnaire consisted of four questions that investigated the main emotions and communication channels most perceived, the expression of empathy, and communicative self-assessment using a scale of 1 to 5 (Appendix 1).
Data analysis
Quantitative variables were presented using mean and standard deviation. Data normality was verified using the Shapiro-Wilk test. Data were analyzed using descriptive statistics to characterize the sample and scores.
Agreement between raters was analyzed using the intraclass correlation coefficient (ICC), adopting a random-effects model with absolute agreement. Differences between raters were assessed using the Friedman test. Correlations between the CARE scale, the Empathy Inventory, and self-assessment were examined using Spearman's correlation coefficient.
The differences between sexes in the factors of the Empathy Inventory and in the average value of empathy perceived by the evaluators, according to the CARE scale, were analyzed using the Mann-Whitney test. A significance level of 0.05 was adopted. The analyses were performed using the SPSS statistical software (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.).
RESULTS
The study included 41 students with a mean age of 22 years (±2 years and 5 months), of whom 24 were male (58.5%) and 17 were female (41.5%). Of this total, 39 students were in their first year (95%) and 2 were in their second year (5%). Regarding the race of the sample, 36 students identified as white (87.8%), 3 as mixed-race (7.3%), and 2 as black (4.8%).
The IE scores related to self-perception of empathy were analyzed according to the different types of empathy assessed in the participants (Table 1).
There was no significant difference in the means in relation to sex and age in any of the factors. The EI factors did not show significant correlations with age, semester, or communicative self-assessment.
The CARE scale presented a median of 26 points, considering the average of the evaluations from the three judges, revealing an average evaluative score of 52%. This value refers to the classification considered "moderate," in which only 26.8% of the students reached higher levels of empathy, that is, scores above 80%. There was a significant difference between the evaluators (Friedman test, p < 0.001). The agreement analysis showed low agreement between the evaluations (ICC = 0.366) (Table 2).
Perceived empathy, agreement, and differences in judges' ratings on the Consultation and Relational Empathy measure
The items with the highest ratings on the CARE scale were: Item 2 – “Let me tell my story”, Item 3 – “Really listened to me”, and Item 6 – “Showed care and compassion”. The items with the lowest ratings were: Item 9 – “Helped me feel in control”, Item 10 – “Planned care for me”, and Item 1 – “Made me feel comfortable” (Table 3).
Spearman's correlation analysis results did not show a significant association between self-reported empathy, measured by the Empathy Inventory (EI), and empathy perceived by external evaluators using the CARE scale. The correlation between the total EI score and the mean CARE score was practically zero (r = 0.02; p = 0.91), indicating the absence of a linear relationship between the variables (Table 4).
Of the 41 students in the sample, 11 (26.83%) showed a high level of empathy during patient care and obtained a score assigned by the judges above 40 points (80%) on the scale.
The average score students gave themselves for their own communication performance after the patient simulations was 2.97 (±1.9), on a scale of 1 to 5, and 61% of students reported having demonstrated empathy during care.
A comparison between the overall average score on the CARE scale and the self-assessment score assigned by students to their communicative performance demonstrated that both measures converge on a moderate level of empathy and communicative skills.
The most frequently observed communication channel in the sample was non-verbal, and the emotions most identified by the students during the simulation were fear, sadness, and doubt.
DISCUSSION
Empathy manifests itself through cognitive and emotional components, which are related to the factors assessed by the EI (AS, AL, PT, IF) and are expressed through verbal and nonverbal communicative behaviors. The factors of Affective Sensitivity (AS) and Altruism (AL) were the highest-scoring in this sample and are related to the components of emotional empathy and empathic concern, while the factors of Interpersonal Flexibility (IF) and Perspective Taking (PT) were the lowest-scoring and are related to cognitive empathy. These data indicate that the students in this sample tended to perceive themselves better in emotional/affective dimensions than in cognitive ones, a pattern observed in similar research(3,7,12).
In general, the EI makes it possible to identify manifestations of empathy in an individual and, in particular, allows for the assessment of the perception of this ability in specific groups. They may be students and healthcare professionals, being useful for inferring the impact of communication during interactions involving care and the quality of the bond established with the patient. All fundamental aspects for therapeutic efficacy, adherence to treatment, and patient satisfaction(12).
Studies show that students and healthcare professionals tend to have greater ease in mobilizing emotional dimensions and empathic concern, while cognitive empathy, linked to reasoning and negotiation processes, requires greater experience and specific training to be fully expressed in clinical interactions(7,10). More empathetic healthcare professionals may present better clinical outcomes and greater trust from their patients(4,5). However, although empathy is frequently valued in the discourse on good clinical practices, its concrete manifestation during professional interactions is not always evident, especially among students in training in the health field(5,7).
A study that assessed empathy in university students in the health field showed a higher self-perception of affective/emotional empathy in this group compared to students from other fields, and cognitive factors appeared with lower averages in the health group(5). This finding reinforces the idea that, in health professionals, the affective dimension of empathy is more frequently reported than the cognitive one, although both are fundamental(2).
An integrative review on the impact of empathy in medical students indicated that affective empathy contributes more strongly to therapeutic bonds and patient well-being, while cognitive empathy, although essential, is less self-perceived by students(14). Thus, the literature agrees with the data presented in this study, demonstrating that among university students, particularly those in the health field, the emotional factors (AS, AL) of EI tend to be higher than the cognitive factors (IF, PT).
The EI data reveals the level of empathy perceived by the students themselves, according to their behaviors and actions in personal and academic situations. This indicates that they evaluate this skill by relating it to emotional and affective aspects during their interpersonal relationships. The values obtained by the CARE scale indicate the level of empathy for these students attributed by others.
The CARE scale addresses qualitative aspects of healthcare service, and there is no standard cutoff score. However, it is expected that, for more assertive and positive care in terms of interaction quality, these values will be higher than an average score of 80%, considering that all statements on the scale refer to essential aspects of human relationships. The value found in this study confirms values observed in similar research with medical students without professional experience and with those who had a higher level of professional experience but without specific training in health communication(13,15,16).
A systematic review showed that the empathy demonstrated by medical students is consistently lower in the early years, when there is no communication training, with moderate and weak averages in relational aspects(6). Although the participants in this study were in their first and second year of training, the data obtained on the CARE scale were similar to those of research involving resident physicians, medical students with more than two years of training, and physicians with greater professional experience(1,13,16). This may indicate that professional practice is not always directly linked to the development of perceived empathy for others.
The physician is the primary healthcare professional for a large part of the population and often precedes other professionals in seeking diagnoses and necessary referrals. Therefore, the initial contact with this professional must be established effectively, so that the entire therapeutic process occurs efficiently.
In this context, the importance of humanizing healthcare stands out, where communication is a key skill that goes beyond technical competence and involves welcoming, actively listening to, and recognizing the patient in their biopsychosocial entirety(1). This skill fosters the building of bonds, increases the patient's trust in the professional, and contributes to greater adherence to treatment, as well as reducing insecurities and anxieties regarding the care process. Thus, a humanized approach in the first contact not only enhances the doctor-patient relationship but also positively impacts clinical outcomes and satisfaction with the care received(2).
The literature indicates that medical professionals and students who have received specific training in health communication are better evaluated and present higher averages than the values found in this study. That is, a rating equal to or above 80% on this instrument, equivalent to a "very good" or "excellent" score on the CARE scale(14,16,17). The perceived empathy values in this study may be justified by the low professional and patient care experience of these individuals. In experienced professionals, this skill may be perceived more consistently and significantly higher than in students.
Studies reveal, however, that throughout medical training, levels of empathy may decrease, meaning that technical aspects are valued more at the expense of human and relational values. These data indicate that this decline is related not only to emotional overload and stress inherent in the training process, but also to a curriculum model still strongly focused on technical performance, to the detriment of communication and the humanistic dimension of healthcare(6,10,18).
The emotions most identified by students during the simulation reflect a pattern widely described in the literature on health communication. Situations involving bad news or serious diagnoses predominantly evoke negative emotional reactions, with fear and sadness being the most recognizable affective states. More subtle feelings, such as hope or resilience, tend to be less perceived(19,20). Studies indicate that in the early years of training, students demonstrate greater ease in capturing explicit manifestations of suffering, such as crying, anxiety, or expressions of fear. However, they have difficulty dealing with complex or mixed emotions and offering responses that favor the patient's sense of control(15,16).
The SPIKES protocol, an acronym representing six steps for communicating bad news in healthcare—Setting up, Perception, Invitation, Knowledge, Empathy/Emotions, and Strategy/Summary—is widely used and describes the most expected emotions in these contexts, such as anxiety, fear, and sadness. The physician's ability to recognize and respond appropriately to these emotions is directly associated with their perception of empathy for the patient(21). In this sense, the findings of the present study reinforce this perspective by showing that, although students recognized and reported high levels of empathy, they had difficulty expressing it consistently in simulated interactions, especially in managing the patient's emotions. This discrepancy suggests that theoretical mastery of protocols such as SPIKES does not, in itself, guarantee practical competence in dealing with emotionally sensitive situations. Furthermore, it reinforces the need for training that integrates cognitive and behavioral aspects of empathy, with an emphasis on identifying emotional cues, validating the patient's feelings, and constructing appropriate communicative responses, in order to make empathy more perceptible and effective in the clinical context.
Therefore, it is necessary to broaden the sensitivity of these students, not only to perceive obvious negative emotions, but also to pick up emotional signals by recognizing these emotions through non-verbal channels, such as facial expressions and voice.
The data from this study indicated that students may value the factors of Affective Sensitivity and Altruism, dimensions related to emotional empathy and empathic concern, while evaluators more consistently perceived active listening and the demonstration of compassion as strengths in student performance.
The weakest points regarding the perception of students' empathetic behavior were related to patient autonomy and the construction of the initial bond, suggesting that they have greater difficulty in sharing clinical decisions and creating comfort at the beginning of care. This finding indicates that students, still in training, tend to express the affective and relational aspects of empathy in a more discreet and less evident way, both in self-perception and in external evaluation.
The factors with the lowest average scores in the EI showed similarity to the items with the lowest scores in the CARE, highlighting difficulties in exercising more cognitive dimensions of empathy, related to patient autonomy and shared decision-making. These findings reinforce the literature, which indicates that students have greater ease in mobilizing affective dimensions of empathy, considering that cognitive and clinical negotiation dimensions require greater experience and specific training to consolidate in communicative practice(5-7).
The correlation analysis between CARE and EI indicated that students' perception of their performance was not significantly related to how their communication was observed and evaluated externally. This may suggest that although students demonstrated some awareness of their limitations, self-perception was not sufficient to predict the empathy perceived by the interlocutor.
The literature suggests that self-report measures tend to capture empathic intent more than its observable expression, reinforcing the importance of pedagogical strategies that integrate self-assessment and external feedback to promote greater awareness and effectiveness in clinical communication(1,9,13,16).
The significant difference and low agreement between the evaluators' scores on the CARE scale can be explained both by the variability in the expression of empathy by the students during the simulations, and by the subjective nature of the evaluators' judgment. The heterogeneity in the participants' performance suggests that empathic behaviors were not manifested consistently, which hinders the convergence of the evaluations.
Furthermore, since this is an observation-based measure, it is expected that different evaluators will assign different weights to verbal and nonverbal signs of empathy, according to their own references and interpretative criteria(11). Even so, the inconsistency in the results points to the poorly systematized use of communicative empathy as an interpersonal skill.
This interpretation is reinforced by the fact that empathy, especially in simulated clinical contexts, involves multiple dimensions—cognitive, affective, and behavioral—that are not always equally developed by students(5). The absence of structured training and specific feedback can contribute to a more intuitive than intentional expression of empathy, making it less perceptible to observers(3). Furthermore, the simulation context itself can generate interferences, such as performance anxiety and excessive focus on technical aspects of the consultation, which tends to reduce attention to relational elements. Thus, the variability in evaluations not only reflects differences in judgment but also highlights gaps in the consolidation of empathy as an observable and consistent clinical competence.
The relationship between communication and empathy is directly associated with how we perceive and express ourselves in relation to the feelings, behaviors, and intentions of others. Empathy is expressed through verbal and nonverbal communication channels and is understood as a complex communication competence, involving affective, cognitive, and behavioral components. Recognizing this capacity in oneself is an essential skill, especially in contexts involving medical practice and healthcare(3-5).
Therefore, when there is no coherence between perceived empathy and demonstrated empathy, the result of these interactions may not generate connection between individuals, and some aspects may become communicative barriers for one or both of those involved in this process(13). Comparative analysis between these two perspectives allows us to identify possible gaps between empathic intention and how it is perceived by the other in various contexts and, in particular, during clinical care(10,22). Previous studies suggest that the low correlation between these measures may indicate that what the professional believes they are communicating is not always perceived by the interlocutor as empathic behavior(13,23,24).
Studies involving medical care simulations have shown that such procedures bring students closer to real clinical situations and offer opportunities for practical verification of the use of empathy and interpersonal skills. Among the benefits of using this strategy are a significant improvement in self-reported and perceived empathy, improved self-confidence in communication and motivation(11,13,19).
One way to assess self-perceived empathy is through the use of self-assessment protocols, a measure widely used in studies involving this competency(3). Self-perception refers to the subject's ability to perceive aspects within themselves by which they evaluate their own internal states, behaviors, and characteristics, constituting a central aspect of self-awareness and the construction of personal identity. This ability involves cognitive components and enables greater self-regulation and social adaptation in various situations, whether personal or professional. This capacity is developed throughout life in a neurodevelopmental process, especially in brain areas related to metacognition and emotional regulation, such as the prefrontal cortex. Difficulty in self-perception in any area, cognitive or affective, whether underestimated or overestimated, can be a negative factor in emotional self-awareness and, consequently, in the establishment of social relationships and the expression of empathy. Empathy is directly associated with the subject's ability to perceive themselves and others, being an essential factor for assertive social interactions(3,9,11).
The literature indicates that the perception and expression of empathy among the students in the sample are amenable to improvement, as they are interpersonal and behavioral skills. These skills, known as soft skills, are developed throughout life and can be improved both through specific training and professional experience. In this sense, the development of empathy is an essential aspect to be worked on throughout the entire training period of health professionals(3,11,17,20).
Although participants reported positive levels of empathy, according to the EI, the assessment by external observers using the CARE scale revealed less consistent results, suggesting a still limited mastery of this competence. This divergence between what is perceived and what is expressed demonstrates that feeling empathy does not necessarily imply communicating it effectively. This finding converges with previous research on the dissociation between perceived empathy and demonstrated empathy in clinical contexts(17,18,24,25).
The sample, composed of medical students in their first years of training, constitutes a limitation of this study. This characteristic may have influenced both self-reported empathy and its communicative manifestation during simulations, given that the development of this competence is associated with clinical experience and specific training in health communication. Although the findings of this study cannot be generalized due to its methodological limitations, the topic addressed raises relevant reflections on the need to include, from the early years of medical training, content and practices focused on empathy and communication. Such early inclusion favors the gradual and continuous development of these skills throughout the entire training process, allowing them not only to be understood at a theoretical level, but also to be practiced in a practical and contextualized way.
Furthermore, the systematic incorporation of these skills into the curriculum contributes to the training of professionals. They are more sensitive to the emotional needs of patients, with a greater capacity to establish therapeutic bonds and to communicate in a clear, ethical, and humane manner. Investing in the development of communicative empathy from the beginning of undergraduate studies can also reduce the observed gap between self-perception and the effective expression of empathy, favoring more consistent clinical practice aligned with the needs of healthcare(4).
The use of the CARE scale as an assessment tool in this study raises methodological implications, especially regarding the validity of the measure in the investigated context. Originally developed to capture the patient's perception of the professional's empathy in real consultations, the CARE scale is based on the subjective experience of those who directly experience the clinical interaction. When applied in an adapted form and by external evaluators, there is a significant change in the measured construct, where the focus shifts from accessing the empathy perceived by the patient to inferring empathy from the observation of behaviors. This transposition may compromise the initial validity of the instrument, since empathy, as a relational phenomenon, depends not only on observable signs but also on the patient's internal and contextual experience during the clinical encounter.
From this perspective, the low agreement among the evaluators highlights weaknesses in the reliability of the assessments. This result suggests that the criteria for judging empathy were not sufficiently aligned among the evaluators, or that the empathic behaviors expressed by the students were subtle, ambiguous, or inconsistent, making their objective identification difficult. Furthermore, the lack of more robust training and clear anchors for interpreting the scale items may have increased inter-rater variability. It is also important to consider that empathy involves multiple dimensions, both verbal and non-verbal, which are not always fully captured in audiovisual recordings, which may have influenced different interpretations of the same interaction.
Despite these limitations, the use of the CARE scale proved relevant in the context of this study, since it is one of the most widely used and internationally validated instruments for assessing empathy in clinical settings(13). The choice of CARE was based on its ability to measure empathy from observable behaviors related to clinical communication, such as active listening, demonstration of interest, emotional validation, and bonding, aspects directly aligned with the objectives of this study. Furthermore, even when applied by external observers, the scale maintains its relevance by offering a structured and systematic framework for analyzing the interaction. This allowed for greater standardization in the assessment of a construct that is, by nature, complex and multifaceted.
Speech-language pathology is the science that studies communication. Therefore, it can act as a strategic area for the development of communicative and empathic skills in health education, favoring the development of these competencies to qualify more conscious, expressive, and humanized professionals(3). Thus, the results of this study lead to reflection on the need for educational practices that transcend self-perception and promote the conscious manifestation of empathy in real encounters with others.
In this context, the inclusion of speech-language pathology content and practices in health education can contribute to the improvement of active listening, vocal expressiveness, nonverbal language, and the functional adequacy of communication in healthcare. Strategies such as simulations with structured feedback, training in communicative skills, and emotional perception exercises can broaden students' awareness of how their communication impacts the therapeutic relationship.
When addressing the components of empathic communication, Speech-Language Pathology offers concrete tools for students to develop not only empathic intention, but also its clear and effective expression. Furthermore, strengthening empathy as an observable competence demands continuous and integrated pedagogical approaches throughout training, and not just isolated interventions(20).
Therefore, Speech-Language Pathology positions itself as an essential field for mediating the development of communicative empathy, contributing directly to the improvement of healthcare and the building of more effective and humanized relationships.
CONCLUSION
Although the medical students in the sample presented positive self-reported levels of empathy, this characteristic was not consistently manifested in clinical simulations. The absence of a significant correlation between self-reported empathy and empathy perceived by external evaluators points to a gap between internal perception and the observable expression of this competence. This finding reinforces the need to promote, within medical training, educational experiences that integrate empathetic feeling and action, so that empathy becomes an authentic and effective communicative practice.
From a scientific point of view, these results contribute to the understanding of the complex dimensions of empathy in care contexts; socially, they point to the urgency of investing in the training of professionals capable of establishing more humane, ethical, and responsive relationships with their patients.
Perceiving and demonstrating empathy in a coherent and assertive manner is an important strategy for fostering positive interpersonal relationships in healthcare. It benefits both patients, whose needs are more likely to be understood, and professionals, who can communicate their ideas and information with greater clarity and precision. Empathy is a key element for communication and connection with others.
Appendix 1 Self-Assessment of Communication in Patient Care
1- What emotions did you identify in the patient during the simulation?
A. Sadness
B. Joy
C. Fear
D. Doubt
E. Anger
F. Boredom
G. Contempt
H. Disgust
2- What most caught your attention about the patient during the simulation?
A. Voice
B. Words
C. Body language
3- Based on your performance in this assistance, rate it from 1 to 5, where 1 is poor and 5 is excellent.
A. 1
B. 2
C. 3
D. 4
E. 5
4- Was it possible to demonstrate empathy for the patient during the consultation?
A. Yes
B. No
C. I'm not sure
Annex 1. Empathy Inventory (EI)(12)
Name:_______________________________________________________ Date: / /
Below you will find a series of statements describing reactions in various social situations. Read each one carefully and answer how often these statements would apply to you, marking the number according to the scale below. Check all the questions.
Use the following key:
| 1 | 2 | 3 | 4 | 5 |
| never | rarely | usually | almost always | always |
| 1 | When I make a request, I try to make sure it won't cause inconvenience to the other person. | 1 | 2 | 3 | 4 | 5 |
| 2 | I would postpone the decision to end a relationship if I realized that my partner was having problems. | 1 | 2 | 3 | 4 | 5 |
| 3 | If I'm in a hurry and someone insists on continuing the conversation with me, I immediately end the conversation by simply saying that I have to go. | 1 | 2 | 3 | 4 | 5 |
| 4 | When someone does something that displeases me, I freely express my anger. | 1 | 2 | 3 | 4 | 5 |
| 5 | When someone confides in me about a problem, I objectively express my opinion, pointing out their mistakes and successes. | 1 | 2 | 3 | 4 | 5 |
| 6 | I tend to put myself in the other person's shoes when I'm being criticized, to try to understand their feelings and reasons. | 1 | 2 | 3 | 4 | 5 |
| 7 | When I have to make a request with someone who is busy, I acknowledge how busy they are before making the order. | 1 | 2 | 3 | 4 | 5 |
| 8 | When I receive criticism, I usually defend myself immediately. | 1 | 2 | 3 | 4 | 5 |
| 9 | When I realize that my opinion contrasts with that of the person I'm talking to, I try to express myself more forcefully. | 1 | 2 | 3 | 4 | 5 |
| 10 | Before asking someone to change a behavior that bothers me, I try to put myself in their shoes to understand what leads them to have that attitude. | 1 | 2 | 3 | 4 | 5 |
| 11 | I find it easy to understand another person's point of view, even when they criticize me. | 1 | 2 | 3 | 4 | 5 |
| 12 | Before pointing out a behavior that bothers me in someone, I try to show that I consider their feelings and understand their reasons. | 1 | 2 | 3 | 4 | 5 |
| 13 | When making a request that is incompatible with another person's interests, I try to be persuasive until I get what I want. | 1 | 2 | 3 | 4 | 5 |
| 14 | After listening to a friend who is having problems, I avoid talking about my own achievements. | 1 | 2 | 3 | 4 | 5 |
| 15 | I would refrain from making an important request if it would cause considerable inconvenience to the other person. | 1 | 2 | 3 | 4 | 5 |
| 16 | When I intend to end a relationship, I try to put my decision into practice instead of overthinking it. | 1 | 2 | 3 | 4 | 5 |
| 17 | When I receive criticism, I try to identify the reasons that led the other person to criticize me. | 1 | 2 | 3 | 4 | 5 |
| 18 | When I disagree with the person I'm talking to, I try to listen to them and then demonstrate that I understand their point of view before expressing my own. | 1 | 2 | 3 | 4 | 5 |
| 19 | When someone expresses an opinion contrary to mine, I feel uncomfortable and immediately try to demonstrate my point of view. | 1 | 2 | 3 | 4 | 5 |
| 20 | If someone owes me something, I collect the debt immediately, even if they may have reasons that justify non-payment. | 1 | 2 | 3 | 4 | 5 |
| 21 | Before expressing my opinion on something I disagree with, I try to understand the perspective of all the people involved. | 1 | 2 | 3 | 4 | 5 |
| 22 | It's better to end a relationship with someone right away than to keep putting it off, even if they're not feeling well that day. | 1 | 2 | 3 | 4 | 5 |
| 23 | If I make a request and receive a negative response, I try to understand the other person's reasons, even if I feel frustrated. | 1 | 2 | 3 | 4 | 5 |
| 24 | When someone acts in a hostile manner towards me, I respond in the same way. | 1 | 2 | 3 | 4 | 5 |
| 25 | When I receive criticism, I try to express my understanding of what the other person said to make sure I understood it. | 1 | 2 | 3 | 4 | 5 |
| 26 | When someone makes a request that I cannot or do not want to fulfill, I say "no" without hesitation. | 1 | 2 | 3 | 4 | 5 |
| 27 | I avoid revealing my personal problems when I realize the other person is not doing well. | 1 | 2 | 3 | 4 | 5 |
| 28 | I can fully understand the feelings and reasons of another person who behaved in a hostile or harmful way towards me. | 1 | 2 | 3 | 4 | 5 |
| 29 | Before confiding my problems to a friend, I try to make sure that he is receptive to listening to me. | 1 | 2 | 3 | 4 | 5 |
| 30 | I can't stay silent when I hear someone say something absurd. | 1 | 2 | 3 | 4 | 5 |
| 31 | Before expressing my opinions in a conversation, I try to understand the other person's opinions, especially when they differ from my own. | 1 | 2 | 3 | 4 | 5 |
| 32 | I'm the type who doesn't take insults lying down. | 1 | 2 | 3 | 4 | 5 |
| 33 | I often put myself in the shoes of someone who is revealing a problem to me, to see how I would feel and what I would think if the situation were happening to me. | 1 | 2 | 3 | 4 | 5 |
| 34 | During a conversation, I try to show interest in the other person by adopting an attentive posture. | 1 | 2 | 3 | 4 | 5 |
| 35 | When I notice that someone is behaving in a way that bothers me, I immediately express my dissatisfaction to make things perfectly clear. | 1 | 2 | 3 | 4 | 5 |
| 36 | Before ending a relationship, I put myself in the other person's shoes to assess how they will feel. | 1 | 2 | 3 | 4 | 5 |
| 37 | When making a request that conflicts with another person's interests, I seek to express my sincere recognition of the inconvenience I am causing them. | 1 | 2 | 3 | 4 | 5 |
| 38 | When someone doesn't pay what they owe me, I get very angry and don't hesitate to collect the debt. | 1 | 2 | 3 | 4 | 5 |
| 39 | I stop sharing a successful experience if I sense that the other person is sad or having problems. | 1 | 2 | 3 | 4 | 5 |
| 40 | If I decide to refuse a request, I'll get straight to the point. | 1 | 2 | 3 | 4 | 5 |
Annex 2. CARE Measure (Consultation and Relational Empathy)(13)
After watching the simulation of the consultation, putting yourself in the patient's (actor's) place, you should indicate on the spreadsheet how you felt about each item of the protocol.
| Item | Description | Poor | Fair | Good | Very Good | Excellent | Does not apply |
|---|---|---|---|---|---|---|---|
| 1 | Making you feel at ease (introducing him/herself, explaining his/her position, being friendly and warm towards you, treating you with respect; not cold or abrupt) | ||||||
| 2 | Let you tell your “story” (giving you time to describe your illness completely, in your own words; without interrupting or distracting you) | ||||||
| 3 | Really listening (paying attention to what you were saying, without looking at notes or the computer while you were speaking) | ||||||
| 4 | Being interested in them as a whole person (asking about or learning important details of their life, their situation, without treating them "just like a number") | ||||||
| 5 | To fully understand their concerns (demonstrating that he or she had correctly understood their concerns; not forgetting or disregarding anything) | ||||||
| 6 | Showing care and compassion (demonstrating genuine concern, relating to you on a human level; not being indifferent or insensitive) | ||||||
| 7 | Being positive (having a positive approach and attitude; being honest without being negative about your problems) | ||||||
| 8 | Explain things clearly (fully answering your questions, explaining clearly, giving you adequate information; not being vague) | ||||||
| 9 | Helping you stay in control (by talking about what you can do to improve your health, encouraging you instead of lecturing you) | ||||||
| 10 | Planning together with you what will be done (discussing the possibilities, involving you in decisions to the extent that you want to be involved; not ignoring your points of view) |
ACKNOWLEDGMENTS
To everyone who contributed, in any way, to the completion of this research study.
-
Study carried out at Universidade Federal de Ciências da Saúde de Porto Alegre – UFCSPA – Porto Alegre (RS), Brasil.
-
Data Availability Statement:
Research data is available in the body of the article.
-
Funding:
Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – CAPES, process nº 88882.442869/2019-0.
References
-
1 Han C, Wu Q, Liu C, Wang P. Patient’s perceived empathy can predict doctor-patient relationship in medical interaction. BMC Med Educ. 2025;25(1):741. https://doi.org/10.1186/s12909-025-07117-7 PMid:40528158.
» https://doi.org/10.1186/s12909-025-07117-7 - 2 Pachêco CSG, Gonçalves LH, Silveira DK, Santos N, Lourenço-Júnior AA. Empatia em estudantes de Medicina: análise em função do gênero, semestre e área de atuação. Rev Bras Educ Med. 2022;46(1):e022.
- 3 Behlau M, Barbara M. Comunicação consciente: o que comunico quando me comunico. Rio de Janeiro: Thieme Revinter; 2022. 256 p.
-
4 Pedersen R. Empathy development in medical education: a critical review. Med Teach. 2010;32(7):593-600. https://doi.org/10.3109/01421590903544702 PMid:20653383.
» https://doi.org/10.3109/01421590903544702 -
5 Brunfentrinker C, Gomig RP, Grosseman S. Prevalência de empatia, ansiedade e depressão, e sua associação entre si e com sexo e especialidade pretendida em estudantes de medicina. Rev Bras Educ Med. 2021;45(3):e182. https://doi.org/10.1590/1981-5271v45.3-20210177
» https://doi.org/10.1590/1981-5271v45.3-20210177 -
6 Neumann M, Edelhäuser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996-1009. https://doi.org/10.1097/ACM.0b013e318221e615 PMid:21670661.
» https://doi.org/10.1097/ACM.0b013e318221e615 -
7 Ferreira TLQ, Barros DM, Santos RM, Oliveira ME, Guimarães LS. Avaliação da empatia clínica dos estudantes de Medicina: associação entre inteligência emocional e empatia. Rev Saúde. 2025;11(2):e18952. https://doi.org/10.25248/reas.e18952.2025
» https://doi.org/10.25248/reas.e18952.2025 -
8 Kötter T, Niebuhr F. Empathy as a selection criterion for medical students. Educ Assess, Eval Account. 2022;47(7):1027-41. https://doi.org/10.1007/s11092-022-09387-x
» https://doi.org/10.1007/s11092-022-09387-x -
9 Bagacean C, Cousin I, Ubertini AH, El Yacoubi El Idrissi M, Bordron A, Mercadie L, et al. Simulated patient and role play methodologies for communication skills and empathy training of undergraduate medical students. BMC Med Educ. 2020;20(1):491. https://doi.org/10.1186/s12909-020-02401-0 PMid:33276777.
» https://doi.org/10.1186/s12909-020-02401-0 -
10 Keshtkar L, Ward A, Winter R, Leung C, Howick J. Does empathy decline in the clinical phase of medical education? A study of students at Leicester medical school. PEC Innov. 2024;5:100316. https://doi.org/10.1016/j.pecinn.2024.100316 PMid:39776945.
» https://doi.org/10.1016/j.pecinn.2024.100316 -
11 Chen DC, Pahilan ME, Orlander J. Comparing a self-administered measure of empathy with observed empathy in medical students. J Gen Intern Med. 2010;25(3):200-2. https://doi.org/10.1007/s11606-009-1193-4 PMid:20013070.
» https://doi.org/10.1007/s11606-009-1193-4 - 12 Falcone EMO, Ferreira MC, Luz RC, Fernandes CS, D’Augustin JF, Sardinha A, et al. Inventário de Empatia (IE): desenvolvimento e validação de um instrumento para avaliação da empatia. Psico-USF. 2008;13(1):75-84.
-
13 Scarpellini GR, Capellato G, Rizzatti FPG, da Silva GA, Martinez JAB. Escala CARE de empatia: tradução para o português falado no Brasil e resultados iniciais de validação. Rev FMRP. 2014;47(1):51-8. https://doi.org/10.11606/issn.2176-7262.v47i1p51-58
» https://doi.org/10.11606/issn.2176-7262.v47i1p51-58 -
14 Chen H, Xuan H, Cai J, Liu M, Shi L. The impact of empathy on medical students: an integrative review. BMC Med Educ. 2024;24(1):455. https://doi.org/10.1186/s12909-024-05448-5 PMid:38664799.
» https://doi.org/10.1186/s12909-024-05448-5 -
15 Park KY, Shin J, Park HK, Kim YM, Hwang SW, Shin JH, et al. Validity and reliability of a Korean version of the Consultation and Relational Empathy (CARE) measure. BMC Med Educ. 2022;22(1):403. https://doi.org/10.1186/s12909-022-03478-5 PMid:35614452.
» https://doi.org/10.1186/s12909-022-03478-5 -
16 Howick J, Moscrop A, Mebius A, Fanshawe TR, Lewith G, Bishop FL, et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. J R Soc Med. 2018;111(7):240-52. https://doi.org/10.1177/0141076818769477 PMid:29672201.
» https://doi.org/10.1177/0141076818769477 -
17 Schwartzkopf CT, Alves RT, Lopes PC, Braux J, Capucho F, Ribeiro C. The role of training and education for enhancing empathy among healthcare students: a systematic review of randomised controlled trials. BMC Med Educ. 2025;25(1):469. https://doi.org/10.1186/s12909-025-07038-5 PMid:40170003.
» https://doi.org/10.1186/s12909-025-07038-5 -
18 Sarkis DJ, Lucchetti G, Martins MCM, Ferreira BS, Soares AHO, Ezequiel OS, et al. Effectiveness of different strategies to teach empathy among medical students: a randomized controlled study. Patient Educ Couns. 2025;130:108468. https://doi.org/10.1016/j.pec.2024.108468 PMid:39405589.
» https://doi.org/10.1016/j.pec.2024.108468 -
19 Catarucci FM, Almeida J, Vieira AC, Silva L. Empatia em estudantes de Medicina: efeitos de um programa de gerenciamento do estresse. Rev Bras Educ Med. 2022;46(2):e071. https://doi.org/10.1590/1981-5271v46.2-20210290
» https://doi.org/10.1590/1981-5271v46.2-20210290 -
20 Nascimento SA, Satler CE. Desenvolvimento da empatia em estudantes de saúde: análise das intervenções eficazes. Rev Psicopedag. 2025;42(127):143-53. https://doi.org/10.51207/2179-4057.20250013
» https://doi.org/10.51207/2179-4057.20250013 -
21 Girardi JM, Andrade BAM, Leão FRC, Machado M, Protazio MM, Oliveira MP, et al. O protocolo SPIKES na comunicação de más notícias em saúde: revisão integrativa. Rev Bras Educ Saúde. 2024;14(1):142-50. https://doi.org/10.18378/rebes.v14i1.10218
» https://doi.org/10.18378/rebes.v14i1.10218 -
22 Mercer SW, Maxwell M, Heaney D, Watt GCM. The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract. 2004;21(6):699-705. https://doi.org/10.1093/fampra/cmh621 PMid:15528286.
» https://doi.org/10.1093/fampra/cmh621 -
23 Andersen FA, Johansen ASB, Søndergaard J, Andersen CM, Assing Hvidt E. Revisiting the trajectory of medical students’ empathy, and impact of gender, specialty preferences and nationality: a systematic review. BMC Med Educ. 2020;20(1):52. https://doi.org/10.1186/s12909-020-1964-5 PMid:32066430.
» https://doi.org/10.1186/s12909-020-1964-5 -
24 Mohamed KG, Almarabheh A, Almughamsi AM, Atwa H, Shehata MH. Evaluation of the effect of a communication skills course on medical students’ attitude towards patient-centered care: a prospective study. PeerJ. 2024;12:e18676. https://doi.org/10.7717/peerj.18676 PMid:39670099.
» https://doi.org/10.7717/peerj.18676 -
25 Nagy E, Luta GMM, Huhn D, Cranz A, Schultz JH, Herrmann-Werner A, et al. Teaching patient-centred communication skills during clinical procedural skill training: a preliminary pre-post study comparing international and local medical students. BMC Med Educ. 2021;21(1):469. https://doi.org/10.1186/s12909-021-02901-7 PMid:34479572.
» https://doi.org/10.1186/s12909-021-02901-7
Edited by
-
Editor-in-Chief:
Renata Mota Mamede Carvallo.
-
Associate Editor:
Stela Maris Aguiar Lemos.
Research data is available in the body of the article.
