Enhancing compassion in medical education - a comparative study of the efficacy of clinical clerkships versus simulation-based training methodologies

Abstract

Compassion at follow-up was significantly higher among the clerkship group in this longitudinal study.

Immersion in realistic clinical settings may promote compassion among medical students.

Abstract

Background

Compassionate behavior plays a crucial role in medicine by fostering patient-doctor relationships, enhancing adherence, and improving care quality. While partly innate, compassion can be significantly enhanced through structured educational interventions. Despite recent efforts to integrate compassion into medical curricula, methodological challenges persist, especially in understanding how different environments influence skill expression and development. This study aims to assess the effectiveness of traditional clinical clerkships versus simulation-based training in cultivating compassion skills among medical students.

Methods

This retrospective longitudinal study evaluated the professional behavior and cognitive skills of 133 medical students at Humanitas University, Milan, Italy, over a three-year period from 2021 to 2024. The curriculum emphasizes problem-based learning and professional development through hospital clerkships and simulation-based training. Compassion was assessed quarterly using a standardized scorecard and continuously evaluated via a learning management system, simulation scenarios and objective structured clinical examinations (OSCEs).

Results

In the initial assessment, compassion scores showed no significant difference between the two settings (clerkship: 3.25 ± 0.73, simulation: 3.30 ± 0.69, p = 0.45). Over subsequent evaluations taking place in the following two years, the differences remained non-significant (p = 0.39, p = 0.22) until a notable divergence was observed in later assessments, particularly in the final evaluation at the end of 5th year study (clerkship: 3.54 ± 0.78, simulation: 3.23 ± 1.18, p = 0.023). Clerkship students demonstrated a significant increase in compassion scores over time (+ 0.29, p = 0.023), benefiting from immersive patient interactions that deepened their compassionate behavior. In contrast, simulation scores peaked slightly but not significantly in Year 4 before returning to initial levels (-0.07, 95% CI [-0.24, 0.11]), highlighting the challenge of sustaining compassionate behaviors without ongoing real-world practice.

Conclusion

This study emphasizes the crucial role of deliberate curriculum design in medical education. While simulation-based training offers controlled environments, it incompletely replicates the emotional depth of real patient interactions crucial for sustaining compassion. Integrating compassion-focused training into medical curricula is essential for nurturing compassionate healthcare professionals, urging immediate action to enhance compassion in medical education.

Trial registration

Not applicable. No health intervention has been proposed, and it’s a purely retrospective analysis on an educational methodology.

Introduction

Compassionate behavior, characterized by empathy, kindness, and a genuine desire to help, is fundamental to medical practice [1, 2]. While empathy involves understanding and sharing another’s feelings, and kindness reflects acts of goodwill, compassion extends beyond these qualities by inherently implying a readiness to act to alleviate suffering. Compassion integrates the emotional resonance of empathy with the proactive nature of kindness, creating a unique construct that drives meaningful intervention [3]. It fosters emotional support and interpersonal connections, essential for building strong patient-doctor relationships and achieving positive healthcare outcomes [4]. By bridging understanding with action, compassion becomes a cornerstone of effective medical care, setting it apart from empathy or kindness alone. Research consistently demonstrates a correlation between heightened levels of compassion and numerous benefits, including improved patient adherence [5,6,7], higher quality care [6], and reduced physician burnout [8,9,10,11]. By fostering a sense of meaning, purpose, and engagement in clinical practice, compassion helps counteract the emotional demands of caregiving. Compassionate interactions also break the monotony of routine tasks, creating fulfilling, human-centered experiences that contribute to resilience and satisfaction [12, 13]. These qualities underline the unique and vital role compassion plays in clinical settings, offering a deeper understanding of its critical contribution to the healing process.

Despite substantial evidence supporting the importance of compassionate patient care, the healthcare sector is currently experiencing a compassion crisis, with patients often feeling misunderstood and healthcare providers needing help to express genuine concern consistently [9, 14]. Encouragingly, research has shown that compassion is not solely innate but can be cultivated through life experiences and structured training [15,16,17]. This recognition has influenced medical education, leading to an enhanced focus on understanding and fostering compassionate behavior [18, 19]. Researchers, educators, and policymakers now emphasize the importance of kindness and understanding toward patients’ concerns, exploring methods to instill compassion in medical curricula to effectively educate future physicians [16, 20, 21]. However, there are currently no standardized compassion training protocols, including approaches to prepare, specific behaviors to prioritize, effective evaluation systems, or considerations of how different settings influence compassionate responses [16, 22]. Additionally, the subjective nature of compassion makes it difficult to measure reliably.

To address these challenges, compassion training can start by exploring the nature of suffering, helping learners recognize it in clinical encounters, and developing awareness of subtle cues. Reflective practices can deepen patient engagement, further enhancing compassionate responses. The R.I.M.E. Framework (Reporter, Interpreter, Manager, Educator) offers a structured model to guide this progression. It captures how learners move from gathering and understanding information (Reporter) to actively managing patient care (Manager), with increasing emotional sensitivity and compassionate responses at each stage. All stages of development are influenced by internal and external factors that shape professional growth.

Research groups emphasize the importance of early initiation and the creation of authentic learning environment [23]. Clinical clerkships, for example, immerse students in hospital settings, providing real-world opportunities for early engagement in patient interactions. This immersion, combined with immediate feedback from patients and staff, creates a realistic environment that enhances emotional engagement and supports the continuous development of compassionate behavior [24]. Despite the well-recognized benefits of the real hospital environment, systemic challenges frequently obstruct the broad implementation of compassion training in these settings. Significant barriers include space limitations in clerkship placements, inadequate mentorship opportunities, and time constraints for tutors [24, 25]. Additionally, disparities in resources and hierarchical structures within medical education exacerbate these challenges [25].

In response to these challenges, simulation-based training has gained traction as a valuable complementary approach. By recreating realistic clinical scenarios in high-fidelity settings, this method allows learners to practice and refine their skills in a controlled, immersive environment. Integrating standardized patients into simulated clinical patient scenarios and emphasizing non-technical skills could enhance the training process, providing a focused way to develop communication, compassion, and decision-making abilities in a realistic context [26]. However, concerns remain about its ability to fully replicate clinical complexities and foster genuine emotional responses and compassion [27,28,29]. Direct patient interactions may be critical for medical students to comprehend the full ethical and emotional aspects of patient care, and to trigger real emotional responses.

Ongoing discussions are centered on evaluating the comparative effectiveness of different training environments in cultivating compassion among medical students. These discussions critically question the extent to which various educational settings, such as hospital-based clerkships and simulation-based training, contribute to the development of compassionate care.

To explore these questions, we designed a study based on the R.I.M.E. Framework, evaluating how learners develop compassionate behaviors across various training environments. This framework guided our comparison of hospital-based clerkships and simulation-based training, allowing us to assess their effectiveness in fostering compassion at different stages of professional growth. The findings from this study are crucial for optimizing medical education practices and supporting the development of empathetic healthcare professionals.

Methodology

Study design and participants

This retrospective longitudinal study aimed to assess the professional behavior of 133 medical students over three years. The observation cohort included students that commenced their education during the 2019/2020 academic year and remained active at Humanitas University in Milan, Italy, during data extraction in 2024. Data were analyzed spanning the timeframe from September 2021 to July 2024, corresponding to the students’ third to fifth years of study. Students from previous cohorts who were delayed in their studies for any reason and students joining the cohort at a delayed time due to inward transfers were also included in the analysis.

Training intervention

The Medicine curriculum at Humanitas University prioritizes problem-based learning and the cultivation of professional behaviors, with the Professionalizing Activity Program serving as a central element [30]. Initiated in the third year, this program incorporates hands-on experiences such as hospital rotations, immersive clinical case discussions, and simulation exercises. Aligned with the Humanitas Learning Model, the curriculum follows a well-defined timeline, specifying the goals and activities for each phase of a student’s educational progression. These learning objectives are systematically structured to accompany students’ professional development, focusing on their clinical, technical, and non-technical skills, which are integral to their future medical practice. The objectives are strategically designed to foster reflection, self-empowerment, and a proactive approach to self-directed learning.

During the third year, students take on the role of reporters, gathering information about patients. In the following year, they assume the position of interpreters, actively analyzing patients’ medical issues. Finally, in their final year, students transition to the role of managers, actively engaging with patients and addressing both their physical and emotional needs. Figure 1 provides a detailed outline of all activities and pedagogical objectives, specifying the time commitments for professional activities and the educational focus for each year of study.

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In detail, students engage in clinical clerkships from the third year onwards, averaging nine days per semester initially, increasing to 20 days per semester by the fifth year. These clerkships involve rotations through various hospital wards, both surgical and medical, under the supervision of field-specific tutors trained in methodologies such as briefing, debriefing, and formative feedback. During this time students have an active engagement with actual patients, and are guided and observed by experienced tutors.

Parallel to clinical clerkships, simulation scenarios are conducted over nine days per semester, providing both relational cases and medium- to high-fidelity clinical simulations. Medium-fidelity scenarios focus on learning technical skills and patient-doctor interactions, including explaining procedures and addressing complaints. High-fidelity simulations aim to replicate real-world clinical routines, addressing urgent and prevalent clinical issues such as myocardial infarction, stroke, severe infections, trauma, and other critical medical situations. After each simulation scenario, an in-depth debriefing session is held, allowing students to reflect on their technical and non-technical performance. During this time, they have the opportunity to discuss aspects such as their experience with compassion in the context of the clinical simulation.

Compassion score measurement

A more detailed description of the Humanitas Assessment Framework can be found in the appendix. In short, behaviors such as compassion, as well as other professional qualities, were assessed using a standardized scorecard. This scorecard evaluates both cognitive and professional skills. Sub-dimensions, including language proficiency, information gathering, and professional behaviors such as compassion, integrity, and commitment to learning, were rated on a 4-point scale (ranging from failure [0] to excellent [4]). For instance, a student demonstrating high levels of compassion might be observed attentively listening to a distressed peer, offering thoughtful support, and addressing concerns with sensitivity, thereby earning the highest score of 4. Conversely, a student who dismisses others’ difficulties or responds with indifference might receive a lower score. Assessments were conducted at predefined time points, typically at the end of clinical or simulated experiences, following a structured timeline (see Fig. 1). Additionally, at the end of each semester, students received a Global Evaluation, which reflected their overall performance throughout the period. This final evaluation played a critical role in shaping the student’s overall profile, contributing to their final assessment at the end of the professionalizing pathway. The assessment process was consistent across all evaluations, with equal focus areas and measurements for each activity.

Evaluators

Approximately 90 tutors in hospital settings and 30 in simulation-based training were responsible for assessing and mentoring students. All tutors participated in comprehensive faculty development programs, which focused on standardizing assessments and enhancing their skills in simulation learning, briefing, debriefing, feedback techniques, and the use of assessment tools. Additionally, tutors received specialized training on evaluating compassion skills, learning how to effectively observe, measure and report these behaviors.

To reduce evaluator bias, the standardized training provided to all tutors ensured fairness and consistency in assessments, both across different tutors and within the various Professionalizing Activities. This approach, aimed at minimizing “evaluator bias” or “inter-rater variability,” promoted a unified evaluation process. Regular meetings were held to refine curriculum development, assess training strategies, and ensure alignment with learning objectives. The use of a multi-source feedback system further helped mitigate bias, ensuring consistent and objective evaluations across the program.

Data analysis

To analyze trends and differences in compassion scores, missing evaluations were imputed using the median score of peers in the same setting and time point. Changes over time within each setting were assessed using the Friedman test, while a mixed linear regression model identified significant score variations. Compassion scores between hospital and simulation-based settings were compared using the Wilcoxon signed-rank test for paired data, enabling assessment of compassion levels and changes over time in both environments.

Results

Study design and participants

Out of 150 undergraduate students who started their studies in the 2019/2020 academic year, 133 (89%) were included in the evaluations. Among them, 125 students (94%) began and completed their studies at Humanitas University during the assessment period, while eight students (6%) transferred to Humanitas from other institutions. These evaluations spanned from the 2021/2022 to 2023/2024 academic years, covering their third to fifth years of study. The cohort was balanced in terms of age and gender, with a slight majority of females (82 participants, 62%) compared to males (51 participants, 38%).

Among the students, 84 (63%) were of Italian origin, 14 (11%) were from other European Union countries (excluding Italy), and 35 (26%) were non-EU students. Compassion score evaluations were available for an average of 130 students (SD +/- 5) over the three years. On average, each student received one score per semester in the first three semesters, three different scores in the fourth semester, and an average of 1.9 scores in the fifth semester.

Compassion score development during the clerkship experience over time

During the clerkship experience, students initially began their evaluation with a mean compassion score of 3.25 (+/- 0.73) (ranging from a minimum of 0 to a maximum of 4). This score improved over time, plateauing at 3.60 (+/- 0.84), reflecting sustained enhancement with a final score of 3.54 (+/- 0.78) and a relative improvement of 0.29 points (confidence interval: 0.12 to 0.47) relative to the initial evaluation (p = 0.001).

Table 1 shows the results of a mixed linear regression model for the Clerkship Observation over time, demonstrating the improvement in compassionate behavior in the hospital setting.

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Compassion score development during the simulation experience over time

When observed within the clinical simulation scenario, students initially were evaluated to have demonstrated a mean compassion score of 3.3 (+/- 0.69) Over time, there was a slight initial increase followed by a subsequent decrease in their compassion assessment, resulting in a final variation compared to the initial value of -0.07 points (CI -0.24 to 0.11).

Table 2 shows the results of a mixed linear regression model for the observation in the simulated environment over time. This trend aligns with findings from other studies indicating a decline in the expression of compassion throughout their educational journey.

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Comparison of the efficacy of clerkship versus simulation

In the initial stages of their training, medical students demonstrated similar levels of compassion in both simulated and clerkship environments. As shown in Table 3, no significant differences in compassion scores were observed during the early years of evaluation (e.g., Year III, 1st Semester, P = 0.45). However, by Year IV, 2nd Semester (T3), a divergence in scores became apparent, and this difference reached statistical significance in Year V, 1st Semester (T4), where Clerkship scores (3.54 ± 0.78) exceeded Simulation scores (3.23 ± 1.18, P = 0.023). These findings indicate that the two settings may differ in their capacity to elicit or evaluate compassion as students advance in their training.

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Figure 2 shows that the trend in the compassion scores in both clerkship and simulation activities showed a significant variation, according to the Friedman test (p < 0.001 for both).

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Discussion

In this study, we investigated the effectiveness of two educational settings—clinical clerkships involving real patients contacts and simulation-based training—in developing compassion among medical students. Using longitudinal data collected over multiple years, we aimed to identify trends in compassion development associated with these distinct training methodologies.

Our findings revealed a positive evolution of compassionate behavior over time among medical students, peaking notably in the fourth year but subsequently demonstrating divergent trends between the two settings. Towards the conclusion of the study period, students displayed heightened levels of compassion in real hospital settings, a progression less evident in simulated environments. Notably, this increase in compassionate behavior was particularly pronounced in the final year of hospital-based training, where students are expected to transition from being a passive observer or “Interpreter” to becoming “Manager”, actively sensing, managing and replying to patient emotions and concerns.

These differences might be explained by experiential learning theory, which emphasizes the importance of real-world engagement in developing complex skills such as compassion. The immersive nature of hospital clerkships allows students to experience authentic emotional and ethical challenges, fostering deeper emotional engagement compared to simulated environments. In clerkships, students confront the complexities of patient care, including ethical dilemmas, confrontation with feelings and the unpredictability of clinical progress. This holistic exposure is crucial for fostering compassion and cultivating patient-centered care [31]. Such experiences are instrumental in promoting genuine compassion, as underscored by psychological studies emphasizing the significance of real-world patient interactions in promoting compassionate behavior [24, 32, 33]. For instance, previous research has shown emotional responsiveness can significantly evolve during clinical clerkships, highlighting the importance of real-world patient interactions in developing emotional engagement and related behaviors [34]. Although the authors focused on empathy in their evaluation, the demonstration of emotional responsiveness and other compassion-related behaviors was significant.

In contrast, simulated environments may struggle to replicate the emotional and psychological demands of genuine patient interactions. While effective in teaching technical and communication skills, simulation-based training may not fully stimulate the emotional responses necessary for sustaining compassionate behaviors over time [35]. Our observations revealed an initial peak in compassionate behavior scores, followed by a decrease back to the initial levels. This highlights a potential limitation of simulated settings in eliciting and maintaining emotional engagement and compassionate responses compared to real-world clinical environments. These findings support existing literature, which suggests that while simulation can introduce compassionate behaviors, it may not elicit the depth required for genuine compassion in authentic patient scenarios [36]. Simulations, while valuable for practicing clinical skills, often lack the emotional complexity of real patient interactions, which challenge students to respond with deeper empathy and personalized care. Thus, while simulations provide a foundation for developing compassion, they may not be enough to foster the profound emotional connections needed in real-world clinical practice.

The implications of our study for medical education are significant. By highlighting the varying effectiveness of different educational environments in fostering compassion, our research underscores the importance of meticulous curriculum design and evidence-based pedagogical strategies. Incorporating compassion-focused training within authentic clinical settings early in medical education offers a comprehensive approach to cultivating essential relational skills critical for personalized patient care.

By bridging the gap between theoretical learning and practical application in a controlled yet realistic environment, medical education can better equip students to navigate the complexities of patient care with compassion. These strategies are vital for developing a new generation of healthcare professionals who possess both technical proficiency and a deep understanding of patient-centered care.

Reflecting on the strengths and limitations of our study, we acknowledge several vital points. A significant strength is that this is a first longitudinal study investigating the impact of environment on the expression of emotions, specifically focusing on compassion. The perceived differences between learning environments in fostering compassion provide valuable insights into educational strategies for compassion development and measurement. Our robust methodology effectively captures longitudinal data on this critical competency, significantly contributing to the existing body of knowledge. By examining compassion scores over time, we can observe trends and the development of different approaches, offering a comprehensive understanding of how compassion evolves when students are exposed to more or less engaging and realistic environments. Additionally, our large sample size and numerous evaluations strengthen the significance and reliability of our findings.

However, we also recognize several limitations. The retrospective nature of our study may introduce inherent biases, and the complexity of measuring compassion competencies through faculty evaluations can impact objectivity. Despite having an assessment tool, observer bias is always possible, potentially affecting our evaluations’ accuracy. Furthermore, a potential limitation is the reliance on a broader professional behavior assessment tool. This approach may not isolate compassion-specific behaviors, as scores could reflect other professional competencies such as commitment to learning. Acknowledging this, future studies could incorporate tools specifically validated for compassion measurement and inter-rater reliability assessments for observer ratings. Nevertheless, by comparing the two approaches, we mitigate the impact of potential observer bias, as the comparative analysis provides a reference point that helps balance and validate the findings. This comparative framework ensures a more nuanced and balanced interpretation of the data, enhancing the overall robustness of our study.

Future research should consider prospective and longitudinal study designs and explore additional methodologies for teaching and assessing compassion on a longer-term impact on patient care. Expanding the scope of research to include diverse healthcare settings and populations can further enhance our understanding of how best to cultivate compassion in medical professionals. However, there is a need for more robust tools to assess compassion in medical education.

Conclusion

In conclusion, our study contributes valuable insights into the complex interplay between educational interventions and compassion development in medical students. We lay the groundwork for informed decision-making in curriculum development and educational policy by elucidating clinical clerkships’ and simulation-based training’s strengths and limitations. Moving forward, sustained efforts to prioritize compassion training are essential for nurturing a generation of healthcare professionals committed to delivering compassionate and patient-centered care.

Data availability

We used anonymised data which are currently stored in our local data warehouse. The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

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