Objectives: Most medical schools focus upon aspects of interpersonal functioning such as empathy in the doctor-patient relationship with the aim of training clinically competent doctors. This study investigated the relationship between empathy and clinical competence among medical students. Methods: Fifty-seven medical students participated in the study. Clinical competence was assessed in an objective structured clinical examination (OSCE). Empathy was rated by an independent observer of the clinical interaction in OSCE stations. In addition, empathy was self-rated using the Jefferson Scale of Physician Empathy-Student Version. Results: Observed behaviour indicative of empathy, as rated objectively by an independent observer, was strongly associated with clinical competence. The strong association between the behavioural manifestation of empathy and clinical competence was evident across a range of medical conditions and types of consultation. In addition, observable empathy was strongly associated with patients' ratings of the students' performances. Self-rated empathy, however, was not associated with clinical competence. Significant differences in mean total competence scores were noted between students low in observed empathy (mean ± standard deviation [SD]: 165.86 ± 12.92) and students high in observed empathy (mean ± SD: 190.35 ± 14.00) (t = 6.28, p = 0.000, α ≤ 0.01). Conclusions: In medical education, strategies that enhance the behavioural expression of empathy (or at least retard its decay) could help to make medical students appear to be more clinically competent to both examiners and patients. However, if medical students' internal emotions are found to be discrepant with their behaviour, these findings will raise difficult questions regarding the fundamental nature of genuine empathy and alert us to the possibility that medical students may learn that it pays to subscribe to the view that if a person does not feel empathy, he or she can fake it.