Introduction: Medical education is committed to promoting empathic communication. Despite this, much research indicates that empathy actually decreases as students progress through medical school. In qualitative terms, relatively little is known about this changing student relationship with the concept of empathy for patients and how teaching affects it. This study explores that knowledge gap. Methods: Adopting a constructivist paradigm, we utilised a research approach new to medical education: Love and Breakup Letter Methodology. A purposive sample of 20 medical students were asked to write love and break up letters to ‘empathy for patients’. The letters were prompts for the focus group discussions that followed. Forty letters and three focus group discussions were thematically analysed. Results: The three major themes were: art and artifice; empathic burden; and empathy as a virtue. Students were uncomfortable with the common practice of faking empathic statements, a problem exacerbated by the need to ‘tick the empathy box’ during examinations. Students evolved their own empathic style, progressing from rote empathic statements towards phrases which suited their individual communication practice. They also learned non-verbal empathy from positive clinician role-modelling. Students reported considerable empathic burden. Significant barriers to empathy were reported within the hidden curriculum, including negative role-modelling that socialises students into having less compassion for difficult patients. Students strongly associated empathy with virtue. Conclusions: Medical education should address the problem of inauthentic empathy, including faking empathic s in assessments. Educators should remember the value of non-verbal compassionate communication. The problems of empathic burden, negative role modelling and of finding empathy difficult for challenging patients may account for some of the empathy decline reported in quantitative research. Framing empathy as a virtue may help students utilise empathy more readily when faced with patients they perceive as challenging and may promote a more authentic empathic practice.
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