Background <p>Little is known about how simulation-based learning and clinical clerkship—two key learning contexts—shape medical students’ interaction with simulated and actual patients and influence students’ clinical empathy. This study investigated the development of clinical empathy among medical students from simulation-based learning to clerkship in China.</p> Methods <p>Adhering to the consolidated criteria for reporting qualitative research (COREQ), this study employed an exploratory qualitative approach in a constructivist paradigm and used thematic analysis to gather and analyze the qualitative data. Data were collected through semi-structured interviews with eight fifth-year medical students and observations of 26 instances among 16 fourth-year students in a six-station objective structured clinical examination. Thematic analysis was used to analyse the qualitative data.</p> Results <p>In simulation-based learning, medical students focused on refining their clinical skills. Although they rarely seldom perceived simulators as real patients, they demonstrated empathetic concern in a performative manner to meet clinical standards. Furthermore, constrained by the lack of timely simulator feedback, they could inadvertently misscritical steps in clinical procedures. During clerkship, medical students experienced stronger emotional responses. Concern about potentially harming patients made students more cautious in procedural steps. Medical students gradually recognized patients’ uniqueness, becoming attuned to emotional cues and alleviating patient suffering by improving their clinical skills. Moreover, their perspective on patients shifted, enabling them to see patients as a whole to carry out medical procedures with empathetic concern.</p> Conclusions <p>While simulation provides skill training, its procedural nature limits empathy development. Clerkship, in contrast, fosters medical students’ emotional engagement, individualized thinking, and flexible views of patients.</p>