Background: Role-playing is widely used to foster empathy and perspective-taking in medical education, but the underlying psychological mechanisms remain unclear. This study investigated whether actual role enactment enhances engagement compared to imagination alone, and how immersive role-play influences students’ emotional and cognitive processes.

Methods: Sixty second-year medical students participated in a two-stage intervention: the Imagination Stage (imagining being a patient or caregiver) and the Role-Playing Stage (actively enacting both roles in a counterbalanced design). After each stage, students wrote reflections. Language use was analyzed using the Chinese version of the Linguistic Inquiry and Word Count (LIWC) tool. Function word frequency was used to calculate the Level of Engagement (LOE). Along with affective and cognitive word usage, these measures provided insights into students’ psychological processes. Human ratings of empathy and perspective-taking were conducted by trained psychology students.

Results: Reflections from the Role-Playing Stage—particularly in the caregiver role—showed significantly higher LOE compared with the Imagination Stage. Higher LOE scores correlated with increased human-rated empathy and perspective-taking. LIWC analysis revealed that patients used more first-person pronouns and negative emotion words, while caregivers used more third-person pronouns, conjunctions, causation, and discrepancy words. Role-playing also led to a decrease in first-person pronouns, negative emotion words, and anxiety words, with an increase in conjunctions and certainty words.

Conclusion: Immersive role-play enhances students’ emotional and cognitive engagement beyond imagined scenarios. Objective linguistic analysis provides valuable insights into learners’ psychological processes, highlighting the pedagogical value of immersive role-play in fostering empathy and perspective-taking in medical education.