The Clinical Learning Environment as a Structural Determinant of Empathy and Burnout in Medical Trainees: A Scoping Review

Empathy is a foundational clinical competency with well-documented associations with patient outcomes, diagnostic accuracy, therapeutic alliance, adherence to treatment, and overall patient satisfaction. However, a consistent body of empirical evidence demonstrates that empathy declines significantly across the trajectory of medical training, most markedly during the clinical years, when direct patient contact is greatest and empathic engagement is most professionally demanded. This paradox — that the environment most requiring empathy is the one most associated with its erosion — has not been adequately explained by the existing literature, which has focused predominantly on intervention efficacy rather than on environmental determinants. Concurrent with documented empathy erosion, learner burnout has reached epidemic proportions in medical education globally. Prevalence estimates range from 37% to over 80% depending on the measurement instrument, training stage, and geographic context. Burnout and empathy erosion are not independent phenomena: depersonalization, a relational withdrawal component of the Maslach burnout construct, is mechanistically and conceptually proximate to empathy decline. Yet the literature has historically treated these as parallel rather than interacting constructs, studying them in largely separate research streams. The clinical learning environment (CLE) which encompasses supervisory relationships, workload structures, institutional culture, hidden curriculum transmission, peer dynamics, psychological safety, and the organizational characteristics of clinical training settings, is increasingly recognized as a primary contextual determinant of both trainee wellbeing and professional identity formation. Despite this recognition, no scoping review has systematically mapped the evidence on how specific, measurable dimensions of the CLE relate to both empathy trajectories and burnout outcomes simultaneously in medical trainees. Existing reviews have addressed adjacent territory: the causes of empathy decline (qualitatively), the efficacy of empathy-training interventions, or burnout prevalence and correlates in isolation. What remains unmapped is the intersection, specifically, how the structural features of clinical training environments function as determinants of both empathy and burnout, and what this implies for educational reform. This represents a significant and consequential gap, with direct implications for curriculum design, accreditation standards, supervisory practice, and institutional wellbeing policy. Furthermore, the existing literature on both empathy and burnout in medical education is geographically skewed toward high-income, predominantly English-speaking contexts. The extent to which findings are transferable to low- and middle-income country (LMIC) settings — where the majority of the world's physicians are trained — remains largely unexplored. This scoping review will explicitly map the geographic distribution of evidence as a dimension of its synthesis