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Medical students often begin training with psychological and physiological health metrics superior to their age-matched peers. By graduation, however, rates of depression, anxiety, and physiologic dysregulation are markedly higher, reflecting the cumulative strain of long study hours, high-stakes examinations, and the emotional burden of early patient care. Despite this, few medical schools provide structured, evidence-based tools for students to develop resiliency and recovery skills before clinical rotations begin.
This gap represents both a health crisis and an educational opportunity. Burnout originating in medical school often persists into residency and practice, diminishing empathy and professionalism, and contributing to long-term attrition. Existing wellness offerings are largely reactive, relying on voluntary counseling or broad wellness sessions that fail to provide individualized insight into students' physiological readiness or stress recovery capacity. Moreover, schools lack objective, continuous data to pinpoint when students are physiologically stressed to tailor timely support.
Against this backdrop, this study proposes evaluating a structured performance coaching and biometric feedback approach in the context of scheduled academic stressors. Arena Strive is a digital coaching platform that integrates a virtual human performance coach, wearable-derived biometric data, and a focused skills curriculum adapted from other high-stress domains and tailored to frontline healthcare workers. This novel intervention has proven effective in significantly reducing burnout and enhancing professional fulfillment and self-valuation in a large health-system through an 8-week intervention.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Arena Strive | Experimental | digital coaching platform, which integrates asynchronous coaching, two virtual coaching sessions with a high-performance medicine coach, physiological data from wearable sensors, and a focused curriculum of performance tools tailored to frontline healthcare workers. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Arena Strive | Behavioral | integrates asynchronous coaching, two virtual coaching sessions with a high-performance medicine coach, physiological data from wearable sensors, and a focused curriculum of performance tools tailored to frontline healthcare workers. |
| Measure | Description | Time Frame |
|---|---|---|
| Heart Rate Variability | Mean daily nocturnal Heart Rate Variability (HRV): Higher = Better | Weekly through Week 13 |
| Resting Heart Rate (Beats per Minute) | daily nocturnal Resting Heart Rate (RHR): Lower = Better | Weekly through Week 13 |
| Sleep Duration (minutes) | Mean nightly sleep: Higher = Better | Weekly through Week 13 |
| Sleep Consistency (minutes) | SD of mid-sleep time: Lower = Better | Weekly through Week 13 |
| Measure | Description | Time Frame |
|---|---|---|
| Change in Perceived Stress (Perceived Stress Scale PSS-4) Scores | To score the Perceived Stress Scale 4 (PSS-4), first, reverse the scores for questions 2 and 3 (0 becomes 4, 1 becomes 3, 2 stays 2, 3 becomes 1, and 4 becomes 0). Then, add up the scores for all four questions. The total score will range from 0 to 16, with higher scores indicating greater perceived stress. | Weekly through Week 13 |
| Measure | Description | Time Frame |
|---|---|---|
| Exam Performance checklist | Exam performance for the three exams during the study period is self-reported by participants via a typeform in the application at the study conclusion. | Week 13 |
| Weekly mean nocturnal HRV (RMSSD, ms) measured via wearable device during intervention and compared to other phases. |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Dermot Phelan, MD, PhD | Wake Forest University Health Sciences | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Wake Forest University Health Sciences | Winston-Salem | North Carolina | 27157 | United States |
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| ID | Term |
|---|---|
| D000077062 | Burnout, Psychological |
| D013315 | Stress, Psychological |
| ID | Term |
|---|---|
| D001526 | Behavioral Symptoms |
| D001519 | Behavior |
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first-year medical students from Wake Forest School of Medicine
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| Change in Burnout (Maslach Burnout Inventory MBI-GSS) Scores | MBI-GSS scoring involves summing responses for each of its three subscales: emotional exhaustion, cynicism, and professional efficacy, which are rated on a 7-point frequency scale from 0 (never) to 6 (daily). To determine burnout, high scores on exhaustion and cynicism indicate higher burnout, while low scores on professional efficacy suggest greater burnout. These subscale scores are then interpreted separately to understand the level of burnout for each dimension. Each item is rated on a frequency scale (e.g., 0 to 6), and higher or lower scores on each subscale indicate different levels of burnout. | Week 13 |
HRV will be assessed using the root mean square of successive differences (RMSSD, ms) to provide a daily individual score derived from nightly photoplethysmography (PPG) wearable-recorded data. All primary endpoints are computed at the individual level and compared by week, using week-level means (averaged from the individual daily scores). Heart Rate Variability (HRV) [RMSSD, ms] Individual Test= Like earlier mentioned tests these will include week-to-week differences for the weeks during the phase (Baseline Week, Study Week, Exam Week, Recovery Week) (ex. HRV_Recovery (during) - HRV_Exam (during) and comparisons with pre/post intervention phases (ex. HRV_Recovery (during) - HRV_Recovery (pre-intervention)). Group Test= A linear mixed model for HRV and PSS-4 with fixed effects for Week, Phase (0=pre, 1=post, 2=during) and a Week x Phase interaction, plus a random intercept for participant. Sensitivity Analyses= Paired t-tests (Wilcoxon as nonparametric alternative). |
| Weekly through Week 13 |
| Weekly mean nocturnal RHR (bpm) measured via wearable device during intervention and compared to other phases. | Daily mean RHR (bpm) will be derived from nightly PPG wearable-recorded data. All primary endpoints are computed at the individual level and compared by week using week-level means (averaged from the individual daily scores). Resting Heart Rate (RHR) [bpm] Individual Test= Like earlier mentioned tests these will include week-to-week differences for the weeks during the phase (Baseline Week, Study Week, Exam Week, Recovery Week) (ex. RHR_Recovery (during) - RHR_Exam (during) and comparisons with pre/post intervention phases (ex. RHR_Recovery (during) - RHR_Recovery (pre-intervention)). Group Test= A linear mixed model for RHR and PSS-4 with fixed effects for Week, Phase (0=pre, 1=post, 2=during) and a Week x Phase interaction, plus a random intercept for participant. Sensitivity Analyses= Paired t-tests (Wilcoxon as nonparametric alternative). | Weekly through Week 13 |
| Weekly mean Sleep Duration (min) measured via wearable device during intervention and compared to other phases. | Daily Sleep Duration (min) will be derived from nightly PPG wearable-recorded data. All primary endpoints are computed at the individual level and compared by week using week-level means (averaged from the individual daily scores). Sleep Duration [min] Individual Test= Like earlier mentioned tests these will include week-to-week differences for the weeks during the phase (Baseline Week, Study Week, Exam Week, Recovery Week) (ex. SleepDuration_Recovery (during) - Sleep Duration_Exam (during) and comparisons with pre/post intervention phases (ex. SleepDuration_Recovery (during) - SleepDuration_Recovery (pre-intervention)). Group Test= A linear mixed model for Sleep Duration and PSS-4 with fixed effects for Week, Phase (0=pre, 1=post, 2=during) and a Week x Phase interaction, plus a random intercept for participant. Sensitivity Analyses= Paired t-tests (Wilcoxon as nonparametric alternative). | Weekly through Week 13 |
| Weekly Sleep Consistency (SD of mid-sleep time, min) measured via wearable device during intervention and compared to other phases. | Sleep Consistency will be measured as the standard deviation of nightly mid-sleep time derived from wearable-recorded sleep onset and offset times over each 7-day period, aggregated weekly at the individual level and compared across pre-intervention, intervention, and post-intervention phases. Sleep Consistency Individual Test= Like earlier mentioned tests these will include week-to-week differences for the weeks during the phase (Baseline Week, Study Week, Exam Week, Recovery Week) (ex. SleepConsistency_Recovery (during) - SleepConsistency_Exam (during) and comparisons with pre/post intervention phases (ex. SleepConsistency_Recovery (during) - SleepConsitency_Recovery (pre-intervention)). Group Test= A linear mixed model for Sleep Consistency and PSS-4 with fixed effects for Week, Phase (0=pre, 1=post, 2=during) and a Week x Phase interaction, plus a random intercept for participant. Sensitivity Analyses= Paired t-tests (Wilcoxon as nonparametric alternative). | Weekly through Week 13 |
| Heterogeneity of effects (sensitivity only) | Moderation by demographics (age, race, gender) on primary outcomes. | Weekly through Week 13 |