Background <p>Narrative medicine has been increasingly advocated as a means of fostering empathy in medical education; however, empirical evidence integrating both effectiveness and processes underlying empathy development remains limited, particularly in non-Western contexts. This study aimed to evaluate the impact of a narrative medicine–based interdisciplinary course on medical students’ empathy and to explore how such an intervention facilitates empathic development.</p> Methods <p>A convergent parallel mixed-methods design was employed in this single-center pilot study. Third-year undergraduate clinical medicine students from Shanghai University &amp; Health Sciences were randomly assigned to an intervention group (<InlineEquation ID="IEq1"><EquationSource Format="TEX">\(n = 40\)</EquationSource></InlineEquation>), which received an 8-week narrative medicine course including close reading, parallel chart writing, and reflective group discussion, or to a control group (<InlineEquation ID="IEq2"><EquationSource Format="TEX">\(n = 40\)</EquationSource></InlineEquation>) that followed the standard curriculum. Quantitative data were collected using the Jefferson Scale of Empathy–Student Version (JSE-S) before and after the intervention and analyzed using descriptive statistics, independent t-tests, and analysis of covariance (ANCOVA) to examine short-term changes in self-reported empathy-related attitudes. Qualitative data were obtained through post-intervention semi-structured interviews and analyzed using reflexive thematic analysis to provide contextualized insights into students’ perceived learning processes and to help interpret the quantitative findings.</p> Results <p>After adjusting for baseline scores, the intervention group was associated with higher post-intervention self-reported overall empathy scores and higher scores in the cognitive dimension of empathy than the control group (<InlineEquation ID="IEq3"><EquationSource Format="TEX">\(p &lt; 0.05\)</EquationSource></InlineEquation>). No significant between-group difference was observed for the Compassionate Care subscale. Qualitative analysis identified four core themes: (1) a shift from a disease-centered to a person-centered perspective; (2) enhanced narrative-based communication; (3) emotional resonance and reflective processing; and (4) narrative practices as resources for coping and professional growth. Integration of findings suggests that narrative medicine education may support early cognitive and affective processes related to empathy, with behavioral expressions of compassionate care potentially developing over a longer period.</p> Conclusion <p>This mixed-methods study found that a structured narrative medicine course was associated with short-term changes in medical students’ self-reported empathy-related attitudes, particularly in cognitive and reflective dimensions. By integrating quantitative outcomes with qualitative insights, the findings highlight empathy as a dynamic process and suggest that incorporating narrative medicine into undergraduate medical education may be beneficial, with behavioral outcomes to be evaluated in future longitudinal studies.</p>