A randomised controlled multicentre trial conducted in 13 Tuscan hospitals shows that a training pathway based on tele-simulation significantly increases empathy levels in newly hired physicians. Structured according to the Kalamazoo model, the 12-hour online course combined role-play, simulation with standardised patients and personalised feedback. The findings open new perspectives for relational training in healthcare: empathy is not an innate gift, but a measurable and trainable clinical competence.
“Doctor, I don’t quite know how to explain it to you…” The standardised patient pauses. They already know that this pause is the real test. They are not waiting for the diagnosis: they are waiting for a look, a question, a signal that on the other side there is someone who is truly listening. Anyone who works with patients knows the power of that suspended moment, and how difficult it is to teach. A multicentre study conducted in Tuscany shows, however, that it is possible: empathy can be trained, measured, and developed. Even in a simulated tele-visit.
Empathy and care: a clinical competence to be trained
Empathy is now considered one of the pillars of the doctor-patient relationship [1]. Although it is a multidimensional concept [2], it is defined as “a behaviour that allows one to understand the experience of the other, distinguishing it from one’s own, producing positive effects on both parties in the relationship” [3]. Evidence shows that the empathy of the healthcare professional is associated with numerous benefits: greater satisfaction of patients and caregivers, reduction of patient anxiety and distress, better therapeutic adherence, and improved clinical outcomes [4]. For health professionals too, empathy represents a protective factor, capable of reducing litigation and protecting against burnout.
Empathic capacities are neither static nor innate; they can change over the course of life and be developed through training. Numerous literature reviews demonstrate that communication training increases empathy levels in healthcare professionals [5-6], particularly when they include specific educational methods and personalised feedback.
Traditional training in communication competencies has significant limitations: empathy tends to decrease during university education and in the first years of clinical practice [7-8]. Scientific data highlight the need for more effective educational approaches and innovative tools such as simulation, which is particularly promising also in contexts of telemedicine and tele-visits.
Scientific data highlight the need for more effective educational approaches and innovative tools such as simulation.
Communicative simulation and the Kalamazoo model
In the field of clinical communication, one of the most established references is the Kalamazoo Consensus Statement (KCS) [9], which identifies seven essential elements of doctor-patient communication and promotes task-oriented, patient-centred learning.
The Kalamazoo model has been applied in numerous educational contexts [10-16]. Its diffusion is linked to the possibility of translating communicative principles into observable and assessable behaviours, a characteristic that makes it particularly suited to simulation.
With the spread of telemedicine, the principles of patient-centred communication have been extended to tele-simulation. Training and assessing communicative behaviours in a simulated environment allows these models to be adapted to the remote visit. Empathy therefore becomes a priority educational competence also in the context of the tele-visit.
Simulated tele-visit: the training pathway
To evaluate the impact of communication training in tele-simulation, a randomised controlled multicentre study [17] was conducted between September 2021 and April 2022, involving newly hired physicians in 13 hospitals in north-western Tuscany. A total of 129 physicians aged between 31 and 42 were enrolled, randomly assigned to a group that received the training (72 participants) or to a control group (57 participants). All participants initially carried out a 45-minute simulated tele-visit with a standardised patient. At the end of the experience, physicians in the trained group received personalised feedback from a course instructor and were invited to participate in a communication course, while the control group received neither feedback nor immediate training. Empathy levels were measured in both groups before the intervention and after 4 to 6 weeks.
The training, structured according to the evidence-based communicative model of the Kalamazoo Consensus Statement, was delivered entirely online for a total duration of 12 hours and included simulation activities and role-play accompanied by structured individual feedback. Simulation constituted the methodological core of the course, allowing participants to observe, discuss, and repeat communicative behaviours, consolidating learning.
The training sessions addressed the main dimensions of patient-centred communication: from the opening and structuring of the encounter to the facilitation of the patient’s narrative, from active listening to paraverbal communication. Specific attention was dedicated to the development of empathy and the understanding of the patient’s perspective. The overall objective of the pathway was to favour the shift from a disease-centred approach to a person-centred one.
Empathy increases with training
The results of the study show a significant improvement in empathy scores in the group that received the training, assessed through two validated instruments: the Toronto Empathy Questionnaire (TEQ) and the Balanced Emotional Empathy Scale (BEES). In both the TEQ and BEES scales, the trained participants recorded a significant increase in scores, while the control group showed a slight decrease in the former and no change detected in the latter. In summary, the physicians who had not followed the training maintained stable or declining values, while those who had participated in the tele-simulation showed a measurable improvement consistent with the educational objective. As already documented in the literature, women presented higher baseline scores than men; after training both genders showed progress, while maintaining the starting differences.
Empathy between simulation and innovation
The results of the study confirm that empathy can be taught and trained and that simulation proves to be one of the most effective tools to do so. Through simulation, participants experience the relationship with the patient, experimenting with communicative dynamics firsthand. At the same time, the simulated environment and the personalised feedback ensure psychological safety. In this way, behavioural learning is fostered.
An innovative element of the study was the delivery mode of the course, entirely online. Despite the debate on the effectiveness of distance training for relational competencies, the results demonstrate that even through tele-education, empathy can be developed effectively. Online simulation can be highly interactive and individual feedback retains its effectiveness, allowing participants to consolidate concrete empathic behaviours.
Beyond the educational effects, tele-simulation offers significant practical advantages:
- It allows costs to be reduced.
- It engages participants from remote locations.
- It extends training to more people without proportionally increasing trainers’ resources and time.
Since telemedicine is destined to grow, training empathy in the tele-visit becomes an integral part of contemporary clinical competence, transforming the doctor-patient relationship also in contexts mediated by technology.
Implications for healthcare training
The results of the study have important implications for the design of training programmes in the healthcare sector. They confirm that empathy is not simply an innate personal trait, but a competence that can be taught and developed early in the careers of professionals. To favour its acquisition, it is essential to adopt active methods, which go beyond theoretical lessons and put participants in concrete relation with the patient. In this context, simulation is confirmed as particularly effective, offering a safe environment in which to observe, practise, and improve communicative behaviours. Experience also demonstrates that tele-simulation represents a practical and scalable solution, capable of extending training also to physicians operating in different locations. Intervening early is crucial since empathy tends to decrease during university training and in the first years of clinical activity.
Conclusions
This study demonstrates that a communication course based on tele-visit simulation, structured according to the Kalamazoo model, is able to significantly increase empathy scores in newly hired physicians compared to a control group. The results confirm that empathy is a trainable competence and that simulation, even in online format, represents a tool to develop it in a concrete way. In an increasingly digital healthcare system, integrating tele-simulation into relational training is not only feasible but necessary. Promoting empathy through simulation means strengthening the quality of the care relationship and, ultimately, improving outcomes both for patients and professionals.
This article was produced in collaboration with “Il colloquio clinico: Rivista italiana di comunicazione sanitaria” (The Clinical Interview: Italian Journal of Health Communication).
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