Abstract: Objective: To examine the determinants of the accuracy with which physicians assess metastatic cancer patient distress, also referred to as their empathic accuracy (EA). Hypothesized determinants were physician empathic attitude, self-efficacy in empathic skills, physician-perceived rapport with the patient, patient distress and patient expressive suppression. Methods: Twenty-eight physicians assessed their patients’ distress level on the distress thermometer, while patients (N =201) independently rated their distress level on the same tool. EA was the difference between both scores in absolute value. Hypothesized determinants were assessed using self-reported questionnaires. Multilevel analyses were carried out. Results: Little of the variance in EA was explained by physician variables. EA was higher with higher levels of patient distress. Physician-perceived quality of rapport was positively associated with EA. However, for highly distressed patients, good rapport was associated with lower EA. Patient expressive suppression was also related to lower EA. Conclusion: This study adds to the understanding of EA in oncological settings, particularly in challenging the common assumption that EA depends largely on physician characteristics or that better rapport would always favor higher EA. Practice implications: Physicians should ask patients for feedback regarding their emotions. In parallel, patients should be prompted to express their concerns.