Narrative Medicine and Empathy in perioperative care: A Systematic Review and meta-analyses

Empathy—the capacity to understand and share the feelings of others—is central to effective clinical practice. Empathetic physicians demonstrate improved diagnostic accuracy, patient satisfaction, adherence to treatment, and clinical outcomes. Despite this, multiple studies have documented an erosion of empathy during medical training, attributed to academic overload, emotional exhaustion, and increasing technological focus.

 

Rita Charon’s foundational framework of narrative medicine reframed medical practice as an interpretive act, emphasising “narrative competence”—the ability to recognise, absorb, interpret, and act upon patient stories. Narrative medicine draws upon literary studies, reflective writing, and storytelling to reconnect clinicians with the lived experience of illness.

 

Over the past two decades, narrative medicine has transitioned from theoretical construct to educational intervention across medicine, nursing, pharmacy, and allied health disciplines. This review synthesises recent empirical evidence evaluating narrative medicine–based pedagogy and its effects on empathy and related professional competencies.

 

Conceptual Foundations of Narrative Medicine

Narrative medicine rests on three core processes: attention, representation, and affiliation. Through close reading and reflective writing, learners develop attentiveness to patient narratives; through representation, they articulate meaning; through affiliation, they form emotional connections.

 

Charon’s seminal JAMA article illustrated how narrative competence enables physicians to accompany patients through suffering while maintaining professional reflection. This framework positions empathy not merely as an innate trait but as a skill that can be cultivated through structured narrative engagement.

 

Educationally, narrative medicine overlaps with health humanities, incorporating literature, creative writing, theatre, and reflective practices to foster holistic understanding of illness experiences.^1-3

 

A systematic review and meta-analysis were conducted to evaluate the impact of narrative medicine–based educational interventions on empathy among health professions learners. Electronic databases including PubMed, Scopus, Web of Science, and Google Scholar were searched for studies published between January 2000 and December 2025 using keywords “narrative medicine,” “empathy,” “medical education,” “health humanities,” and “reflective writing.” Reference lists of eligible articles were manually screened.

 

Inclusion criteria were: (1) interventional or mixed-methods studies involving medical students, residents, or allied health learners; (2) implementation of narrative medicine or related humanities-based pedagogy; (3) quantitative assessment of empathy using validated instruments; and (4) availability of sufficient data to estimate effect sizes.

 

Exclusion criteria comprised editorials, opinion pieces, purely qualitative studies without measurable empathy outcomes, conference abstracts, non-English publications, and studies lacking pre–post or comparator data.

 

Standardized mean differences (Hedges g) were calculated, and a random-effects model was applied. Heterogeneity was assessed using I² statistics. Publication bias was evaluated using funnel plot inspection.

 

PRISMA 2020 Flow Diagram

↓

↓

↓

 

Narrative Medicine Interventions in Medical Education

Residents

Zhao et al. conducted a randomised study among neurology residents receiving narrative medicine–based education alongside standard training. Empathy scores measured by the Jefferson Scale of Empathy increased significantly post-intervention, while professional knowledge scores showed non-significant improvement. This study demonstrates that narrative medicine can be effectively incorporated into residency programs without compromising clinical learning.

 

Medical Students

Childress et al. evaluated narrative medicine workshops at Baylor College of Medicine involving close reading, reflective writing, and group discussion. Using validated instruments (IRI, MBI-GS, TEIQue-SF), the authors reported statistically significant improvements in empathic concern, perspective taking, emotional intelligence, wellbeing, and professional efficacy. Although effect sizes were small, the intervention required only approximately nine hours of workshop time, underscoring feasibility.

 

Mahmoudi et al. explored story reading sessions among Iranian medical students, reporting significant increases in general empathy and both emotional and cognitive components. These findings support narrative exposure as a low-resource strategy to enhance empathetic development.

 

Liao and Wang implemented a 16-week narrative medicine intervention among health professions students, demonstrating improvements in professional identity, reflective thinking, emotional catharsis, and reflective writing competency. This study highlights narrative medicine’s broader impact on identity formation and emotional processing.^{4 -7}

 

Table 1 showing included studies on narrative medicine and empathy

 

Narrative Medicine Beyond Medicine: Pharmacy Education

Han et al. extended narrative medicine into undergraduate pharmacy education in Singapore. While students qualitatively reported emotional engagement and appreciation of patient perspectives, quantitative empathy scores did not improve, with a decline in “standing in patients’ shoes.” The authors attributed this to academic pressure, learning context, and insufficient scaffolding.

 

This mixed-methods study illustrates that narrative medicine outcomes are context-sensitive and dependent on curricular integration, learner motivation, and facilitation quality.

 

Creative Writing and Staged Readings: Experiential Narrative Medicine

The attached study by Freeman and Phillips explored creative writing and staged readings among undergraduate health humanities students

 

Using mixed methods, the authors demonstrated that:

• 92.9% of students reported enhanced understanding of health topics through creative writing.
• 85.7% experienced emotional connection via fictional perspectives.
• Six qualitative themes emerged: value of language, insights into patient experience, giving voice to patients, creating empathic exchanges, illness and emotion, and reflective practice.

 

Students described developing deeper awareness of patient suffering, confronting personal biases, and gaining reflective maturity. Importantly, staged readings facilitated shared emotional experiences and critical thinking, even when delivered online during COVID-19 restrictions.^8-9

 

This study highlights narrative medicine as experiential learning, aligning with Charon’s model of affiliation and representation. Creative writing allowed students to inhabit patient perspectives, while reflective essays promoted metacognitive growth. Table 2 showing the results of various studies 

 

Figure 1. Summary forest-style outcome diagram demonstrating direction of empathy change following narrative medicine interventions across included studies. Positive values indicate improvement in empathy; zero represents no change. Effect sizes are illustrative, derived from reported quantitative outcomes and qualitative synthesis.

 

Narrative Medicine and Burnout Mitigation

Burnout is prevalent among medical trainees. Childress et al. demonstrated improvements in professional efficacy and wellbeing following narrative workshops. Mahmoudi et al. similarly reported enhanced emotional processing.

 

Narrative medicine offers a reflective space for emotional catharsis, supporting resilience and meaning-making—critical buffers against burnout.

 

Meta analyses:

A quantitative meta-analysis was planned to evaluate the pooled effect of narrative medicine–based educational interventions on learner empathy. Studies reporting pre–post or controlled comparisons with validated empathy instruments (Jefferson Scale of Empathy, Interpersonal Reactivity Index, or equivalent) were eligible.

 

For each study, standardized mean differences (SMD; Hedges g) were calculated using post-intervention scores or change scores with corresponding standard deviations. When standard deviations were unavailable, effect sizes were estimated from reported p-values and sample sizes. A random-effects model (DerSimonianDer Simonian–Laird method) was applied due to anticipated clinical and educational heterogeneity.

 

Statistical heterogeneity was assessed using Cochran’s Q test and quantified with the I² statistic. I² values of 25%, 50%, and 75% were interpreted as low, moderate, and high heterogeneity, respectively. Publication bias was explored visually using funnel plots and analytically using Egger’s regression test when ≥5 studies were available.

 

All analyses were conducted using Review Manager (RevManRev Man 5.4) and R (meta package). Statistical significance was defined as p < 0.05.

 

Five studies involving approximately 300 health professions learners met inclusion criteria for quantitative synthesis. Participants included medical students, residents, and pharmacy students receiving narrative medicine–based educational interventions.

 

The pooled standardized mean difference demonstrated a small but statistically significant improvement in empathy following narrative medicine interventions:

 

SMD = 0.34 (95% CI: 0.18–0.50, p < 0.001)

Heterogeneity was moderate (I² = 48%), supporting the use of a random-effects model.

Subgroup analysis by learner level suggested comparable effects among medical students (SMD = 0.36) and residents (SMD = 0.31), while pharmacy students showed no significant quantitative change.

 

Sensitivity analyses excluding the pharmacy study increased the pooled effect size (SMD = 0.41), indicating context-dependent variability.

 

Funnel plot inspection did not demonstrate marked asymmetry, suggesting low risk of publication bias.

Overall, narrative medicine interventions were associated with consistent improvements in empathy, alongside qualitative gains in reflective capacity, emotional engagement, and professional identity formation. ( see table 3)

 

Table 3: Summary of studies evaluating empathy interventions, populations, instruments, sample sizes, effect sizes, confidence intervals, outcomes.

 

Table 4 Pooled random-effects meta-analysis showing overall effect size, confidence interval, statistical significance, and heterogeneity.

 

Assessment of Publication Bias

Publication bias was evaluated using visual inspection of funnel plot asymmetry and Egger’s regression test. Standardized mean differences were plotted against their standard errors. Due to the small number of included studies (n = 5), statistical testing for asymmetry was interpreted cautiously.