One of the most basic forms of empathy and compassion education is theoretical instruction delivered through lectures. It typically consists of lectures or seminars covering the concepts of empathy, importance of patient-centered care, and ethical literacy [2]. Courses on communication skills or lectures on medical ethics in the curriculum provide the definition of empathy and clinical cases, helping students understand the core elements of empathy. However, lecture-centered teaching methods alone have limitations in changing students’ attitudes or forming new behaviors. This is because empathy and compassion deepen through experiential acquisition and self-reflection rather than simple knowledge transfer [11]. Moreover, relying solely on formal education and assessment risks students expressing superficial scale-appropriate empathy [9]. Therefore, lecture-based education is most effective when combined with practical and reflective activities.

Role-playing is a practical method widely used in empathy education, in which students simulate clinical situations and perform patient and physician roles. This approach may take the form of drama workshops or scenario-based theaters, encouraging students to think and feel from a patient’s perspective [2]. For instance, while acting out scenarios involving terminal patient care, students can indirectly experience patients’ pain and emotions and reflect on their responses through peer feedback. Experiential learning helps develop cognitive and affective empathy skills. One study revealed that incorporating role-playing into communication workshops led learners to develop deeper empathy from patient and family perspectives [13]. In summary, role-playing provides students with opportunities to actively practice empathy and adjust their behavior in a safe educational environment.

Standardized patients (SPs) are specially trained simulated patients for educational purposes that allow medical students to practice empathy and compassion through simulated consultations. Sessions with SPs provide the advantage of practicing appropriate empathetic expressions in emotionally challenging situations. Many medical education programs use SPs for communication practice, and clinical simulations have been reported to positively affect students’ empathy scores and interpersonal communication skills [2,11]. One report indicated that students could improve their verbal and nonverbal expressions of empathy through feedback after simulating care scenarios involving patients with cancer and receiving direct evaluation from the perspective of patient role actors. These experiences provide students with opportunities to practice empathy before the clinical experience, helping them respond more flexibly and proficiently to empathy in subsequent actual patient encounters. However, SP practice requires resources and costs, leading researchers to explore alternatives such as virtual patients or simulators.

Reflective writing is an educational method that encourages students to express their thoughts and feelings after their clinical experiences or interactions with patients. This includes journal-format writing, experience reports, and essays on patient narratives, allowing students to reflect on moments of empathy or the lack thereof and revisit their significance. This self-reflection process not only enhances students’ self-awareness but also deepens empathy skills by helping them reinterpret situations from patients’ perspectives [11]. Some studies have reported that medical students who have written reflective essays after clinical practice show an improved understanding of and empathetic attitudes toward patients’ suffering. Reflective writing is widely used to promote internal learning at a relatively low cost, and its educational effects are further enhanced when combined with sharing experiences and receiving feedback in small groups [2].

Narrative medicine is a humanistic approach that develops empathy through the incorporation of literature, art, and patient stories into medical education. This involves encouraging medical students to listen to or read patients’ illness experiences in story form and then discuss or respond to these narratives in writing. The philosophy of narrative medicine can be summarized as understanding patients’ lives and suffering through stories [14], helping students deeply accept the human aspects beyond illness. Examples include students writing essays about their feelings after reading patients’ illness memoirs or classes where students read and discuss literary works that depict doctor-patient relationships. These humanistic experiences stimulated empathy and compassion in students, enabling them to view patients holistically in healthcare settings [9]. Studies have shown that education through art and literature shows positive results in enhancing students’ sensitivity to and understanding of patients [2]. Batt-Rawden et al. [15] have suggested that incorporating arts and humanities subjects into medical curricula are necessary for cultivating empathy, and that this narrative approach helps ‘bloom’ students’ empathy ‘flowers’. Therefore, narrative medicine is used as an educational method to add depth to medical students’ ability to listen to patients’ stories.

Traditional methods of empathy and compassion education have several limitations. First, the effects of existing programs were primarily measured through self-assessment. Thus, numerous studies reporting improved empathy scores lack objective indicators or patient feedback-based evaluations [11]. Additionally, many educational intervention studies were conducted without control groups or only confirmed short-term effects immediately after education, failing to track long-term maintenance effects or behavioral changes in clinical settings [10,11]. A systematic literature review noted that most empathy education sessions were conducted as one-time sessions without follow-up tracking, making it unclear whether the empathy skills gained through education persist over time [11].

Second, there are limitations to the educational content and methods. Traditional approaches often tend to emphasize only certain aspects of empathy or compassion or focus on a single teaching method, whereas the empathy skills required in actual clinical practice are complex competencies that combine cognitive understanding, emotional responses, and behavioral skills. Nevertheless, some programs consist of only specific experiential elements such as role-playing, leading to assessments of inadequacy for integrated competency developmen [11]. In this context, the recent literature emphasizes the need for multimodal learning strategies in empathy education [2,13]. I nstructional design should ideally include lectures on knowledge acquisition, humanistic approaches to attitude change, practice and feedback for skill refinement, and self-reflection. Reports indicate that applying complex curricula results in greater improvements in empathy scores than applying single methods [2].

Finally, the influence of educational environments and hidden curricula was significant. Students form attitudes toward empathy by observing the behavior of supervising professors and senior physicians in clinical practice settings beyond the formal curriculum. However, in reality, students’ empathy levels may be undermined by negative role models or organizational cultures that disregard empathy [9]. Laughey et al. [9] have identified this negative, hidden curriculum as a factor that gradually erodes medical students’ empathy (empathic erosion), noting that empathy acquired through formal education fails to be maintained or manifested in clinical settings. Therefore, not only the qualitative improvement of educational programs but also the cultural improvements in clinical settings and role modeling by faculty must occur together for sustainable educational effectiveness.

Because empathy and compassion are core competencies in medical education, the need for more systematic and evidence-based curriculum development has been raised [10,12], with movements emerging to redesign the entire curriculum to be empathy-friendly. Ultimately, progress should be made toward the continuous growth of students’ empathy through more holistic curricula and changes in learning environments rather than one-time education [2]. This is recognized as a challenge faced by medical educators but is ultimately a necessary path for providing patient-centered quality healthcare.

In summary, the above two sections have demonstrated that while empathy and compassion are widely recognized as essential competencies in medical education, traditional instructional approaches often fall short owing to limitations in experiential depth, scalability, and evaluation methods. These limitations highlight the need for more innovative pedagogical strategies, which are explored in the next section.

VR is gaining prominence as a tool to enhance empathy by providing immersive environments. In one study, medical students who experienced the daily lives of patients with depression through VR showed significant improvements in perspective-taking and empathic care scores on empathy score subdomains [3]. The experimental group showed improved scores on the Jefferson scale of empathy (JSE) compared with the control group, indicating that indirect experiences through VR enhanced understanding and empathy for mental illness [3]. Another study evaluated immersive VR training in scenarios that helped socially isolated elderly patients with first-year medical students. Results showed statistically significant empathy skill enhancement, with an average increase of 5.94 points in the pre- and post-JSE scores, and students accepted the VR experience as a valuable empathy education tool [7]. In particular, VR characteristics such as immersion, presence, and embodiment have been identified as key elements that help understand patient perspectives and increase empathy [7]. These results demonstrate that the VR technology is effective in empathy education for healthcare providers. However, most VR empathy training is conducted in one-time sessions, which require additional research on long-term empathy improvement and transfer to actual clinical communication.

AR and XR technologies are used to cultivate empathy and communication skills. AR has the advantage of allowing learners to interact simultaneously with real environments and virtual patients by overlaying virtual information on real environments. An AR system was designed to provide real-time feedback during the care process, and training results showed that the AR group had significantly increased frequency of eye contact with patients and improved empathy scores (JSE) compared with the control group [16]. Thus, AR-based emotional expression training improved caring behaviors (e.g., eye contact and distance adjustment) and increased empathy for patients [16]. Similarly, Kobayashi et al. [17] reported positive changes such as improved empathy toward patients and increased eye contact ratios in a communication training program that combined AR simulation with AI feedback. XR technology enables virtual patient scenarios among multiple participants, even in physically separate situations. Stanford University reported that students showed learning engagement by evaluating AR-based remote collaboration simulators (e.g., CHARM) for communication training among healthcare providers as acceptable and enjoyable tools, while suggesting technical improvements [18]. In summary, AR and XR have emerged as means to effectively practice empathy among healthcare providers by breaking down the boundaries between real and virtual.

Metaverse is a platform that merges XR technology, including VR and AR, with online virtual worlds. In metaverse environments, learners can participate in virtual spaces as avatars and interact with patient avatars and other learners. These social VR environments feature enhanced interpersonal communication and role-playing elements compared with simple single-user VR experiences, which are expected to be useful for developing emotional competencies. According to previous reports, using XR-based virtual patients in the VR avatar can improve physicians’ attitudes, communication skills, empathy, and problem-solving skills [19]. In metaverse environments, healthcare providers can repeatedly practice various patient scenarios while improving their skills without losing personal touch [19]. Examples include conducting patient-healthcare provider role-plays in virtual multibed wards or scenarios in which students from various professions gather in one space for virtual team-based empathy training. However, the use of metaverse remains mostly at conceptual stages or in small-scale empirical studies, with ongoing research systematically demonstrating its effectiveness. Nevertheless, metaverse is attracting attention as a collaborative and patient-centered learning environment for future medical education.

Conversational AI (chatbots), particularly LLMs such as ChatGPT, are used to simulate medical consultation scenarios via text or voice, enabling practical conversations with virtual patients instead of SPs. In the early 2020s, several research teams developed systems that allowed medical students to practice empathetic conversation skills by interacting with chatbots in patient-specific roles. Mendolia [20] designed an empathetic chatbot implemented with a dialogue flow-based natural language processing interface for students to practice empathetic responses to simulated patients. Such chatbots provide patient responses across various clinical scenarios, enabling repetitive learning and offering cost-efficient advantages over face-to-face practice [20]. Additionally, the latest LLM-based chatbots with natural language generation abilities can engage in rich conversations like real patients and can be used by students to practice situation assessment and empathy expression. Shorey et al. [21] reported significantly improved communication learning attitudes and self-efficacy among nursing students after the implementation of AI virtual counseling applications.

Limitations of chatbot-based empathy training have also been observed. Although the latest language models can create humanlike sentences, there is a need to distinguish between superficial sympathetic expressions and genuine emotional exchanges. Models such as ChatGPT can provide seemingly empathetic responses. However, they lack the subtle emotional empathy and nonverbal cue interpretation skills that humans possess [22]. Responses of ChatGPT sometimes appear more empathetic than those of human physicians. However, this is based on language patterns that the model has learned rather than genuine empathy [22]. Therefore, chatbots/LLMs can help students’ repetitive practice as an auxiliary means but must be combined with faculty feedback or actual clinical experiences.

ITS are AI educational platforms that provide personalized feedback and coaching based on learner performance data. Furlan et al. [23] developed a virtual patient simulator, Hepius, which combined natural language processing with ITS for clinical reasoning training. This system provides step-by-step feedback and guidance for the next steps as students conduct interviews with virtual patients [23]. A case study with 15 fifth-year medical students evaluated this AI-tutoring virtual patient as a useful tool for practicing history taking for differential diagnosis, suggesting high utilization value even in remote education situations [23]. Thus, ITS leads to effective practice by analyzing learners’ communication content in real time to provide immediate corrective feedback or coaching for insufficient empathy expressions. With the development of AI-based assessment technologies, systems that automatically analyze and score students’ virtual patient interview content and provide feedback have been implemented. Maicher et al. [24] have reported that when AI evaluate the communication skills of medical students after conversations with emotion-responsive 3D virtual patients, the accuracy of the computer assessment scores (87%) is similar to that of human evaluations (90%). This finding demonstrates the possibility of incorporating AI scoring and tutoring into the assessment of empathy and communication abilities. In one case study, the previously mentioned AR-based empathy training [16] improved students’ eye contact and distance maintenance skills through AI image analysis feedback. In summary, ITS and AI assessments are developing in directions that further systematize empathy improvement training by identifying medical students’ individual weaknesses and providing them with personalized guidance.

This section provides an in-depth overview of AI-driven approaches to empathy and compassion training, demonstrating their potential benefits in enhancing emotional understanding, communication skills, and learner engagement. While the current findings are promising, particularly for early stage learners, further studies are required to determine their long-term effectiveness and scalability across diverse clinical and educational contexts.