How does medical education affect empathy and compassion in medical students? A meta-ethnography: BEME Guide No. 57

The integrated curriculum and student empathy: a longitudinal multi-cohort analysis

Research has demonstrated erosion of empathy in students during medical education. Particularly, U.S. studies have demonstrated empathy declines during clinical training in the third and fourth year of traditional medical programs. Yet, studies conducted outside the U.S. have not confirmed this trend. Timing and extent of patient interactions have been identified as empathy-protective factors. The need to examine empathy within different learning contexts has been noted, as has the need for longitudinal and time-series research designs to analyze trajectories. Between fall 2010 and spring 2019, we assessed empathy longitudinally among six student cohorts (N = 493) at a U.S. medical school, where patient interaction occurs early and throughout an integrated curriculum. Empathy levels of students in each cohort were assessed at five time points utilizing the Jefferson Scale of Physician Empathy-Student version. We hypothesized empathy levels will not degrade by program end, and trajectories will not show patterns of decline in Years Three and Four. Analysis of Variance (ANOVA) and Linear Mixed Model (LMM) analyses were used to analyze differences at baseline and changes in empathy trajectories. ANOVA analyses revealed statistically significant differences at baseline by class cohort (F(5, 487) = [23.28], p < 0.001). LMM analyses indicated empathy was either significantly higher or not different at the end of the program (F(19, 1676) = [13.97], p < 0.001). Empathy trajectories varied among cohorts; yet, none resulted in an overall empathy decline by the end of the program. Findings demonstrate empathy in U.S. medical students can be unchanged or higher by the end of medical education. Outcomes are consistent with reports of non-declining medical student empathy outside the U.S. and support the notion of context-specificity. Results further support recent research, suggesting decreases in empathy during training can stabilize or increase by program end. These findings have important implications for future empathy research context and design considerations, as well as program planning.

The current state of empathy, compassion and person-centred communication training in healthcare: An umbrella review

OBJECTIVES

This umbrella review consolidates evidence available on empathy training, its effectiveness and design mechanisms that contribute to effectiveness.

METHODS

We conducted an umbrella review (review of reviews) of empathy, compassion and person-centred communication training in healthcare published between 2018 and 2022. One reviewer screened titles, abstracts and full-text articles, with a second reviewer at full-text stage. Quality appraisal was done in duplicate. Data extraction was piloted by two reviewers and conducted by one reviewer with a quality check of all extracted data. All reviewers provided input into synthesis of results and analysis.

RESULTS

Twenty-five reviews were included. We provide an overview of the definitions of empathy, compassion and person-centred communication, outcome measures used, a synthesis of findings on the mechanisms and effectiveness of training and a summary of review recommendations.

CONCLUSIONS

For policy and practice, we advise the inclusion of empathic communication into the curriculum; longitudinal and sequenced learning; debriefing, targeted feedback, enabling self-reflection, deliberate practice, experiential learning; improving motivation by teaching the benefits of empathy and teaching sustainable empathy. Future research should involve patients in training and research and study the effect of targeting interventions at healthcare practitioners and patients.

Exploring medical students' perceptions of empathy after cinemeducation based on Vygotsky's theory

BACKGROUND

Medical students' empathy toward patients with Alzheimer's is rarely found in formal medical curricula. Based on Vygotsky's theory, watching films and reflection can be considered as effective methods to improve empathy. The present study aimed to explore medical students' perceptions of empathy toward patients with Alzheimer after participating in an educational program by using interactive video based on Vygotsky's theory.

METHODS

This qualitative study was conducted at Tehran University of Medical Sciences in 2022. The population included all 40 medical students. Firstly, the Still Alice movie which is about the feelings of a professor who was diagnosed with Alzheimer's disease was shown to the students. Secondly, the students reflected on their experiences of watching the movie. Thirdly, a session was held for group discussion on the subject of the movie, the patient's feelings, the doctor's attitude, the social environment surrounding the patient shown in the movie, and the necessity of empathy toward patients with Alzheimer's disease. The reflection papers were analyzed using the conventional qualitative content analysis method.

RESULTS

After analyzing 216 codes from 38 reflection papers, four categories, including communication with a patient with Alzheimer's, understanding the patient with Alzheimer's as a whole, medical science development, and the student's individual ideology, were extracted.

CONCLUSION

Reflection and group discussion after watching movie by providing opportunities for social interaction about personal interpretations will lead to active role in enhancing empathy. Based on the perceptions of the medical students, they gained a perspective to consider the patient as a whole and pay attention to establishing a proper relationship with the patient.

Talking about dying and death: Essentials of communicating about approaching death from the perspective of major stakeholders

OBJECTIVES

Although caring for dying patients and their family caregivers (FC) is integral to patient care, training in communication about approaching death is almost inexistent in medical and nursing curricula. Consequently, many health professionals have insufficient knowledge about conducting these conversations. In order to gain a broader insight into essential aspects of this communication from different perspectives, we conducted focus groups with key stakeholders.

METHODS

Medical specialists, nurses, medical students, bereaved FC and patient representatives participated in five focus groups (n = 30). Following a focus group schedule, we elicited relevant aspects of communication about approaching death, associated emotions, and appropriate communication frameworks. We analyzed data thematically.

RESULTS

Four main themes were central to conversations about approaching death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others.

SIGNIFICANCE OF RESULTS

Communicating about approaching death with dying patients and their FC can be complex and challenging at a professional and personal level. With the recognition of the dying phase, a process is initiated for which health professionals need solid clinical knowledge about but also effective communication skills, constant self-reflection and self-care strategies. Comprehensive training and supervision while dealing with the challenges of communicating approaching death to dying patients and their FC are key, particularly for trainees, less experienced physicians and nurses. The essential components identified in this study can help health professionals to master these conversations.

Predictors of Medical Students' Compassion and Related Constructs: A Systematic Review

Phenomenon: Compassion, and related constructs such as empathy, are core values in healthcare, with known benefits for both patients and staff. Yet research on the factors that affect compassion and compassion-related constructs remains scattered. This review systematizes and synthesizes studies investigating the predictors of compassion and related constructs among medical students, allowing for a better understanding of the factors that both positively and negatively contribute to the development of compassionate future physicians. Approach: A systematic review of 12 databases for studies from database inception up until April 2020 was conducted. Non-peer-reviewed literature and studies in which >50% of the sample were non-medical students were excluded. Intervention studies were also out of the scope of this review. We assessed risk of bias and confidence in the findings using standardized tools. Data were categorized within the Transactional Model of Physician Compassion, a framework in which compassion is influenced by personal (student), environmental, patient/family, and clinical factors. Findings: Of 14,060 retrieved articles, 222 studies were included. Of these, 95% studied student factors, but only 25% studied environmental, 9% studied patient, and 6% studied clinical factors. Predictors of greater compassion included maturity; work and life experiences; personality traits of openness to experience and agreeableness; skills such as perspective taking, reflection, and mindfulness; and positive role modeling. Conversely, negative attitudes/emotions, burnout, stress, detachment, operating in cultures prioritizing knowledge and efficiency over humanistic care, negative role models, time constraints, and heavy workloads predicted lower compassion. Patient-related factors included "difficult" and "noncompliant" patients or those perceived as responsible for their illness. Overall, 60% of studies had a serious risk of bias, particularly confounding and participant selection biases. Insights: Medical student compassion is predicted by a wide range of factors relating to the student, their training environment, their patients, and the clinical situation. However, existing research has largely focused on student factors (e.g., sociodemographic and dispositional traits), many of which are not amenable to intervention. Skills such as perspective taking, reflection, and mindfulness are associated with higher compassion and may present opportunities for intervention. There is also strong evidence that environmental factors shape students' compassion. Researchers and educators should continue to explore the impact of patient and clinical factors on students' compassion. Studies remain at high risk of bias.

Implementation of virtual OSCE in health professions education: A systematic review

INTRODUCTION

The Objective Structured Clinical Examination (OSCE) has been widely used in health professions education since the 1970s. The global disruption caused by the COVID-19 pandemic restricted in-person assessments and medical educators globally sought alternative means to assess and certify students and trainees to meet the acute demand for health-care workers. One such solution was through virtual OSCE (vOSCE), which modified traditional in-person OSCE using videoconference platforms. This meta-ethnography sought to synthesise qualitative literature on candidates' and assessors' experiences of vOSCE to evaluate whether it may have a role in future assessment practices.

METHODS

In June 2022, we systematically searched PsycINFO, Medline and ERIC for peer-reviewed qualitative and mixed-methods articles that described candidates' and assessors' experiences of virtual OSCE in health professions education. Of 1069 articles identified, 17 were synthesised using meta-ethnography.

RESULTS

The final synthesis represented 1190 candidates and assessors from faculties of medicine, dentistry, nursing, pharmacy and osteopathy. We developed our findings into four key concepts. 'Strengthening confidence in a virtual environment' highlighted attempts to overcome and mitigate concerns associated with transitioning from in-person to virtual assessment. 'Understanding the scope of use as an assessment' reflected on the suitability of vOSCE in assessing various skills. 'Refining operational processes' emphasised the technical challenges of implementing vOSCE and impacts on accessibility and resources. 'Envisioning its future role' considered the applicability of vOSCE in the climate of rapid development in telehealth.

CONCLUSION

This meta-ethnography highlighted that although vOSCE was primarily considered a temporary and crisis response, candidates and assessors recognised positive, as well as negative, consequences of the transition towards them. Moving forward, medical education policymakers should carefully consider the extent to which elements of vOSCE could be incorporated into assessment systems, particularly in light of the rise of telehealth in clinical practice.

Exploring the Impact of Book Club Participation on Clinicians' Empathy and Reflection on Empathetic Practice: A Wake-Up Call

INTRODUCTION

 Empathy is associated with desirable outcomes in healthcare, including improved patient-clinician rapport, fewer patient complications, and reduced clinician burnout. Despite these benefits, research suggests empathy declines during professional training. This study aimed to explore the impact of book club participation on clinicians' and trainees' empathy and perspectives on empathetic patient care.

METHODS

 In this mixed-methods study, anesthesiology clinicians and trainees were invited to respond to a baseline online empathy survey followed by an invitation to read a book and to participate in one of four facilitated book club sessions. Post-intervention empathy was measured. The primary outcome of the quantitative analysis was a change in empathy scores as measured by the Toronto Empathy Questionnaire. A thematic analysis of book club sessions and open-ended comments in the post-intervention survey was conducted.

RESULTS

 Participants included 74 responders to the baseline survey and 73 responders to the post-intervention survey. Empathy score change in the book club participants was not statistically significant from those who did not participate in any book club sessions (F_{(2, 39)} = 0.42, p=0.66). Thematic analysis of the book club sessions revealed four themes that highlight how the book club enhanced empathy awareness among trainees and clinicians: 1) a wake-up call, 2) deciding whether to take action, 3) learning and nurturing empathy, and 4) changing the culture.

CONCLUSION

 There were no significant changes in empathy scores associated with book club participation. Thematic analysis highlighted barriers toward empathetic patient care, areas for improvement, and voiced intentions to practice with heightened empathy. Book clubs may be a viable venue to nurture a culture of increased self-awareness and motivation to counteract loss of empathy, but just one experience may not be sufficient.

Trends of Change in Empathy Among Indian Medical Students: A Two-Year Follow-Up Study

Background

The development of an empathic approach is essential for doctor-patient relationships. Medical training is a challenging time that may affect empathy. This study aimed to assess the change in empathy in students during medical education.

Methods

One hundred and fifty MBBS students were recruited at admission and assessed for empathy, interpersonal reactivity, and general health. They were followed for two years and assessed at three intervals.

Results

A significant decline was seen in empathy for both male and female students. The decline was correlated with psychological stress. Gender, family structure, having siblings, and increasing General Health Questionnaire score predicted change in empathy.

Conclusion

Empathy declines with advancing training, varying with constitutional and situational factors. The medical curriculum should include skills like empathic communication as well.

Empathy is not so perfect! -For a descriptive and wide conception of empathy

Physician empathy is considered essential for good clinical care. Empirical evidence shows that it correlates with better patient satisfaction, compliance, and clinical outcomes. These data have nevertheless been criticized because of a lack of consistency and reliability. In this paper, we claim that these issues partly stem from the widespread idealization of empathy: we mistakenly assume that physician empathy always contributes to good care. This has prevented us from agreeing on a definition of empathy, from understanding the effects of its different components and from exploring its limits. This is problematic because physicians' ignorance of the risks of empathy and of strategies to manage them can impact their work and wellbeing negatively. To address this problem, we explore the effects of the potential components of empathy and argue that it should be conceived as a purely descriptive and wide term. We end by discussing implications for medical education.

What Matters Most? The Power of Kafka's Metamorphosis to Advance Understandings of HIV Stigma and Inform Empathy in Medical Health Education

HIV stigma, a social-medical problem, continues to confound researchers and health professionals, while undermining outcomes. Empathy may reduce stigma; its absence may predict stigma. This research investigates: How does Kafka's Metamorphosis advance understandings of HIV stigma in medical health education? Metamorphosis amplifies the sociological-relational mechanisms fostering HIV stigma. It offers a multi-disciplinary, responsive space for ethical, humanistic and clinical inquiry to meet: enabling students to consider how social structures shape health inequities, moral, social experience, and their professional identity within. Metamorphosis may ultimately promote medical health humanities' social mission-allowing literature to unfold such revelations towards greater equity in health.

Optimising planned medical education strategies to develop learners' person-centredness: A realist review

CONTEXT

Person-centeredness is a stated aim for medical education; however, studies suggest this is not being achieved. There is a gap in our understanding of how, why and in what circumstances medical education interventions that aim to develop person-centredness are successful.

METHODS

A realist review was conducted with a search of Medline, Embase, HMIC and ERIC databases and the grey literature using the terms 'medical education' and 'person-centred' and related synonyms. Studies that involved a planned educational intervention in medical education with data on outcomes related to person-centredness were included. The analysis focused on how and why different educational strategies interact with biomedical learner perspectives to trigger mechanisms that may or may not lead to a change in perspective towards person-centredness.

RESULTS

Sixty-one papers representing fifty-three interventions were included in the final synthesis. Nine context-intervention-mechanism-outcome configuration (CIMOc) statements generated from the data synthesis make up our refined programme theory. Where educational interventions focused on communication skills learning or experiences without person-centred theory, learners experienced dissonance with their biomedical perspective which they resolved by minimising the importance of the learning, resulting in perspective endurance. Where educational interventions applied person-centred theory to meaningful experiences and included support for sense making, learners understood the relevance of person-centeredness and felt able to process their responses to learning, resulting in perspective transformation towards person-centredness.

CONCLUSION

Our findings offer explanations as to why communication skills-based interventions may be insufficient to develop learners' person-centredness. Integrating experiential person-centred learning with theory on why person-centredness matters to clinical practice and enabling learners to make sense of their responses to learning, may support perspective transformation towards person-centredness. Our findings offer programme and policymakers testable theory to inform the development of medical education strategies that aim to support person-centredness.

Medical Students' Perspectives on the Factors Affecting Empathy Development During Their Undergraduate Training

INTRODUCTION

This study investigated the perspectives of medical students on the factors influencing empathy development during their undergraduate training.

METHODOLOGY

A descriptive phenomenological approach was used to generate illustrations of empathy development and decline that had educational significance and applicability. Individual online semi-structured interviews were conducted to elicit experiential details from twelve final-year medical students. The interview recordings were transcribed verbatim, and data were analysed employing Braun and Clarke's thematic analysis method.

RESULTS

The self-reported empathic behavior of medical students seemed to have improved with time in medical school. Students attributed their empathy development to real patient encounters, positive role-modelling by teachers, and attainment of confidence and personal maturity. They identified exams, academic overload, time constraints, personal stresses, negative role models, unconducive learning environments, and lack of formal empathy training as barriers to empathy development.

CONCLUSION

Medical institutes should identify and address the barriers to empathy development and encourage the holistic development of medical students. Furthermore, medical educators should model their behavior accurately for their increasing roles and responsibilities and support the students in their empathic expressions with patients.

Clinical empathy in GP-training: Experiences and needs among Dutch GP-trainees. "Empathy as an element of personal growth"

OBJECTIVE

Clinical empathy has been described as a key component of effective person-centeredness in patient-physician communication. Yet little is known about general practitioner (GP) trainees' experiences and opinions regarding clinical empathy, empathy-education and the development of empathic skills. This study aimed to explore trainees' experiences with clinical empathy during GP training.

METHODS

This study used focus group interviews. GP trainees at two Dutch universities were approached by e-mail. Focus groups were conducted between April and November 2018. Six focus groups were conducted: two with starting trainees, two with trainees at the end of their first year and two with trainees at the end of their 3 years' training. Two experienced qualitative researchers analyzed the focus groups. During the thematic analysis the differences and similarities between the various stages of education were taken into account and a framework for the identified themes and subthemes was developed.

RESULTS

Thirty-five GP trainees took part. Four main themes could be identified. Starting trainees experienced frictions regarding the influence of personal affective reactions on their medical competencies. Trainees at the end of their first year indicated that they reached a balance between empathic involvement and their responsibility to carry out relevant medical tasks, such as following GP guidelines. Trainees at the end of their three years' training recognized the mutual relationship between the development of the behavioral part of clinical empathy and personal growth. All trainees stated that their needs concerning education changed during their GP training and proposed changes to the curriculum.

CONCLUSIONS

GP trainees face various obstacles in developing empathic skills and behavior. Particularly they mention handling personal affective reactions. Trainees express a clear wish for clinical empathy, in its theoretical as well as its skill and emotional aspects, to play a central role in the curriculum.

PRACTICE IMPLICATIONS

More explicit attention to be paid to empathy by embedding theoretical education, explicit attention to skill training and assessment of empathic behavior by patients and supervisors.

Assessing empathy in final-year medical students using the Persian version of the Jefferson Scale of Physician Empathy

BACKGROUND

A doctor-patient relationship built on the concept of empathy is so essential to attain the best clinical outcomes in medicine. Since empathy has a positive role in interpersonal relationships and medical outcomes, its assessment is highly crucial. The aim of this study was to assess the empathy in last-year medical students using the Persian version of the Jefferson Scale of Physician Empathy (JSPE) and correlate empathy scores with demographic features.

MATERIALS AND METHODS

In this cross-sectional study, last-year medical students at Shiraz Medical School, Shiraz, Iran, were recruited for this study. In this research, we used the Persian version of JSPE. The validity and reliability of the Persian version of this tool were confirmed in the previous research. For the analysis of data, we employed descriptive statistics and the independent sample t-test.

RESULTS

One hundred and eighty-five final-year medical students were included in this study. The maximum score of the questionnaire was 140, and the total mean score of empathy was 98.15 ± 13.29. The females' total mean score (102.05 ± 11.89) was higher than the males' score (93.57 ± 13.46). The difference between the mean score of gender and empathy was significant (P value <.001), but there was no significant difference between empathy and the two other demographic factors (P > 0.05).

CONCLUSIONS

Although physicians would gain the essential characteristics of empathy during their career, attending professors and other responsible policymakers in medical education should focus more on the factors related to physicians' empathy to train better and more professional physicians.

Association of Characteristics of the Learning Environment and US Medical Student Burnout, Empathy, and Career Regret

IMPORTANCE

Previous studies have shown that medical student mistreatment and burnout are common. However, few longitudinal data exist to describe how mistreatment and other learning environment experiences are associated with subsequent burnout and other student characteristics.

OBJECTIVE

To examine the association between mistreatment and perceptions of the learning environment with subsequent burnout, empathy, and career regret among US medical students.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from the 2014-2016 Association of American Medical Colleges (AAMC) Medical School Year 2 Questionnaire (Y2Q) and 2016-2018 AAMC Graduation Questionnaire (GQ). Medical students from 140 allopathic medical schools who responded to both AAMC surveys were included in the analysis. Data were analyzed from December 1, 2019, to January 11, 2021.

EXPOSURES

Self-reported medical student mistreatment (eg, experiences of negative behaviors and discrimination related to sex, race/ethnicity, and sexual orientation) and perceptions of the learning environment (Medical School Learning Environment Survey subscales for faculty, emotional climate, and student-student interactions).

MAIN OUTCOMES AND MEASURES

Burnout, empathy, and career regret as measured by Oldenburg Burnout Inventory data for burnout, Interpersonal Reactivity Index scores for empathy, and a single item assessing career regret.

RESULTS

Data from 14 126 medical students were analyzed; 52.0% were women, and the mean (SD) age was 27.7 (2.9) years at graduation. Mistreatment was reported by 22.9% of respondents on the Y2Q. In multivariable analysis adjusted for Y2Q measures, mistreatment reported on the Y2Q was associated with a higher exhaustion score (1.81 [95% CI, 1.60-2.02]), a higher disengagement score (0.71 [95% CI, 0.58-0.84]), and higher likelihood of career regret on the GQ (186 of 989 [18.8%]; all P < .001). A more positive emotional climate reported on the Y2Q was associated with a lower exhaustion score (for each 1-point increase, -0.05 [95% CI, -0.08 to -0.02]; P = .001) and lower disengagement score (for each 1-point increase, -0.04 [95% CI, -0.06 to -0.02]; P < .001) on the GQ. More positive faculty interactions on the Y2Q were associated with higher empathy score on the GQ (for each 1-point increase, 0.02 [95% CI, 0.01-0.05]; P = .04). Better student-student interactions were associated with lower odds of career regret during year 4 of medical school (odds ratio for each 1-point increase, 0.97 [95% CI, 0.95-1.00]; P = .04).

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that medical students who experienced mistreatment and perceived the learning environment less favorably were more likely to develop higher levels of exhaustion and disengagement, lower levels of empathy, and career regret compared with medical students with more positive experiences. Strategies to improve student well-being, empathy, and experience should include approaches to eliminate mistreatment and improve the learning environment.

"From doing to knowing": medical students' experiences of working as Healthcare Assistants

There is growing recognition that doctors need to deliver person-centered care. More evidence is needed on how to best equip students in an already busy curriculum. Providing medical students with the opportunity to work as Healthcare Assistants (HCAs) can help them develop the desired skills. This study examined medical students' experiences of working as HCAs and perceived impact on their future practice. Adopting an Interpretative Phenomenological Analysis approach, we analyzed narratives from two focus groups of 13 'Year 0' and 'Year 1' medical students, who had completed an HCA project. This project allowed participants to experience a new dimension of patient care whereby learning by "doing" evolved to a deeper level of "knowing" patients, the HCA role and the wider team. Four major themes were identified: seeing the doctor: gaining new perspectives; building confidence: learning from and about patients; understanding the overall patient experience: providing personal care; finding "the person behind the patient": exploring beyond the diagnosis. This study suggests that working as an HCA enables participants to develop sustainable skills that equip them for their future role as doctors able to deliver person-centered care as part of an interprofessional team. Recommendations for inclusion of this type of intervention into the medical curriculum are discussed.

Moral judgement development during medical student clinical training

BACKGROUND

Whereas experience and cognitive maturity drives moral judgement development in most young adults, medical students show slowing, regression, or segmentation in moral development during their clinical years of training. The aim of this study was to explore the moral development of medical students during clinical training.

METHODS

A cross-sectional sample of medical students from three clinical years of training were interviewed in groups or individually at an Australian medical school in 2018. Thematic analysis identified three themes which were then mapped against the stages and dimensions of Self-authorship Theory.

RESULTS

Thirty five medical students from years 3-5 participated in 11 interviews and 6 focus groups. Students shared the impacts of their clinical experiences as they identified with their seniors and increasingly understood the clinical context. Their accounts revealed themes of early confusion followed by defensiveness characterised by desensitization and justification. As students approached graduation, some were planning how they would make moral choices in their future practice. These themes were mapped to the stages of self-authorship: External Formulas, Crossroads and Self-authorship.

CONCLUSIONS

Medical students recognise, reconcile and understand moral decisions within clinical settings to successfully reach or approach self-authorship. Curriculum and support during clinical training should match and support this progress.

Improving Empathy in Healthcare Consultations-a Secondary Analysis of Interventions

A recent systematic review of randomised trials suggested that empathic communication improves patient health outcomes. However, the methods for training healthcare practitioners (medical professionals; HCPs) in empathy and the empathic behaviours demonstrated within the trials were heterogeneous, making the evidence difficult to implement in routine clinical practice. In this secondary analysis of seven trials in the review, we aimed to identify (1) the methods used to train HCPs, (2) the empathy behaviours they were trained to perform and (3) behaviour change techniques (BCTs) used to encourage the adoption of those behaviours. This detailed understanding of interventions is necessary to inform implementation in clinical practice. We conducted a content analysis of intervention descriptions, using an inductive approach to identify training methods and empathy behaviours and a deductive approach to describe the BCTs used. The most commonly used methods to train HCPs to enhance empathy were face-to-face training (n = 5), role-playing (n = 3) and videos (self or model; n = 3). Duration of training was varied, with both long and short training having high effect sizes. The most frequently targeted empathy behaviours were providing explanations of treatment (n = 5), providing non-specific empathic responses (e.g. expressing understanding) and displaying a friendly manner and using non-verbal behaviours (e.g. nodding, leaning forward, n = 4). The BCT most used to encourage HCPs to adopt empathy behaviours was "Instruction on how to perform behaviour" (e.g. a video demonstration, n = 5), followed by "Credible source" (e.g. delivered by a psychologist, n = 4) and "Behavioural practice" (n = 3 e.g. role-playing). We compared the effect sizes of studies but could not extrapolate meaningful conclusions due to high levels of variation in training methods, empathy skills and BCTs. Moreover, the methods used to train HCPs were often poorly described which limits study replication and clinical implementation. This analysis of empathy training can inform future research, intervention reporting standards and clinical practice.