Introduction <p>Narrative medicine has emerged as a promising approach to enhance medical students’ professional competencies, but how it works remains unclear. Understanding whether and how narrative medicine influences professional identity, humanistic care, and empathy is crucial for medical education reform. This study investigated the associations of narrative medicine competencies with three key professional outcomes (professional identity, humanistic care, and empathy), with particular attention to the mediating role of empathy.</p> Methods <p>A cross-sectional survey was performed among 594 medical students in China. Participants completed validated instruments assessing narrative medicine knowledge, narrative literacy, professional identity, humanistic care, and empathy. Multiple linear regression and bootstrap mediation analyses were performed to examine direct and indirect effects.</p> Results <p>Narrative medicine knowledge and narrative literacy are associated with all outcomes. Empathy significantly mediated the relationships between narrative medicine competencies and professional outcomes. For narrative medicine knowledge, empathy accounted for 56.1% (95% CI [43.6%, 71.0%]) of the total effect on professional identity and 61.0% (95% CI [50.9%, 72.0%]) on humanistic care. For narrative literacy, the mediation proportions were 44.1% (95% CI [30.9%, 59.0%]) and 54.1% (95% CI [42.7%, 65.0%]), respectively.</p> Conclusions <p>Empathy statistically mediates the associations between narrative medicine competencies and professional development outcomes. Narrative literacy is associated with professional outcomes through both empathy-mediated and direct pathways, while narrative medicine knowledge operates primarily through empathy. These findings suggest that medical education should prioritize hands-on narrative practices while retaining theoretical teaching to optimize professional development.</p>