The HEART© curriculum yielded measurable improvements in participants’ physiological regulation. Prior to the intervention, HRV recordings from treatment-group participants exhibited the jagged, irregular patterns characteristic of an incoherent autonomic state. These patterns are commonly associated with heightened stress, emotional dysregulation, and reduced physiological resilience. After the five-week training, recordings were smoother, and more sinusoidal, which reflect the increased coherence and improved autonomic balance in the trainees. One participant described this shift succinctly: “Most valuable was learning to calm myself. My grounding calmed the horse too.”

For the representative participant shown in Fig. 1, coherence increased 35% from pre- to post-intervention.

HEART© intervention increased HRV, as evidenced by participant recordings. A HRV recording and metrics from participant 7 before HEART© intervention. Data was collected during a single, three-minute recording using an infrared pulse plethysmograph ear sensor attached to the participant’s ear lobe and analyzed using HeartMath emWave pro software. The y-axis on the left reports beats per minute (BPM), while the y-axis on the right reports HRV in milliseconds. The HRV values are reported in descending fashion, i.e., higher values are closer to the x-axis. (Although they are reported in the table, coherence and number of intervals are not shown on graph for clarity). B HRV recording and metrics from participant 7 after five weeks of HEART© intervention

Similar changes were observed at the group level. Treatment-group participants demonstrated statistically significant increases in HRV, and coherence (p ≤ .05).

Participants often described applying these physiological skills in everyday situations. One student noted, “I found myself going straight into coherence automatically during stressful moments.” Complementing these findings, heart rate decreased slightly while HRV increased, which suggested more stable and organized cardiac rhythms in trainees.

Collectively, these quantitative and qualitative outcomes indicate that participants not only learned coherence-building techniques but were able to shift their physiological state toward coherence (Fig. 2).

HEART© increased HRV and coherence. For each of the panels of Fig. 2 standard error values were calculated by dividing the standard deviation by the sample size square root. A Recordings of very low frequency (VLF), low frequency (LF), high frequency (HF) and total power (TP). To normalize the parameters across treatment group participants, values were transformed to their natural logarithmic values. B Number of R-R intervals, heart rate, and standard deviation of the number of all normal intervals (SDNN) for treatment group participants. The number of R-R intervals represents the average time in milliseconds between two successive R waves. Heart rate (HR) in beats per minute is the average heart rate of treatment group participants. C HRV, defined as the time in milliseconds between R-R intervals, increased as a result of the treatment intervention. D Coherence, expressed as a percentage with values ranging from 0-100%, increased following HEART© intervention. As with HRV, higher values are desirable

Table 3 includes summary statistics, describing pre- and post-implementation RS-14™ and MSWBI scores for both control and treatment groups. The results of the linear mixed effects model for the MSWBI showed that the MSWBI outcome for the treatment group is the only statistically significant change at the 0.05 level of significance (t (16) = -2.22, p = .041), where the mean decreased from 4.22 (SE = 0.601) to 3.00 (SE = 0.601). There was no evidence of a difference between the two groups as a result of the treatment as measured by the model interaction term (F (1,16) = 1.31, p = .270).

Qualitative feedback supported these quantitative findings. Participants commonly described renewed emotional capacity and a greater ability to pause, reset, and engage more intentionally in their daily lives. One participant reflected, “Taking real mental breaks and being present brought back joy.” This narrative aligned with participants’ reports of improved coping, increased resilience, and a greater sense of balance following the intervention.

From the linear mixed effects model for the RS-14™ survey, individually, neither group shows a statistically significant change for the RS-14™ survey; interestingly, a statistically significant difference occurred between the changes in the two groups as measured by the model interaction term (F (1,16) = 4.94, p = .041). The control group experienced a downward trend while the treatment participant group experienced an upward trend in resilience scores.

Participant feedback aligned with these quantitative patterns. Students frequently described feeling better able to recover from stressors and maintain emotional steadiness across academic and clinical demands. One participant expressed this shift succinctly: “This helped me avoid the burnout slide—regulate, refocus, and move on.”

As coding progressed, distinct themes began to become apparent in answers from all participants. Once all transcripts were analyzed and themes finalized, it became clear that the findings could be cohesively and concisely organized using the acronym BALANCE. As one participant observed, “Balance. That’s what health is… When there’s an imbalance, you have disease.” During member checking, treatment group participants affirmed that the acronym BALANCE accurately represented their experiences.

Positive and meaningful interactions are essential to fostering a sense of belonging. Imposter syndrome, marked by self-doubt and fear of being exposed as a fraud, can undermine that sense of belonging and contribute to anxiety and depression. Treatment group participants reported that the EAL experience strengthened their understanding of how emotional self-awareness and compassion support connection. Several students described how the HEART© curriculum equipped them with coping strategies that enabled clearer thinking, more confident decision-making, and reduced self-doubt. As one participant explained, “I didn’t feel like I had to pretend. Everyone there was trying to figure things out, just like me.” Another added, “For the first time in medical school, I felt like I was part of a group where we were allowed to be human.”

Participants highlighted the powerful role that equine interactions played in fostering a sense of belonging and self-connection. Moments of attunement with the horses invited reflection on trust, boundaries, and vulnerability, and many participants noted that the horses’ immediate, unfiltered responses often surfaced emotions they had not yet recognized in themselves. One participant reflected, “I think this was a really cool thing because it’s helping me find my authentic self. It’s helping me listen to myself more and be more in tune with my emotions, which I think would help so much with burnout.” Another described a moment of personal clarity: “Through this experience I am becoming more aware of what makes me, me; and I like who I am. I am finding a confidence that I did not know I had.” Collectively, these experiences underscored how emotional clarity and congruence support authentic connection—both with the horses and with other people.

Participants in the treatment group explained that their prior understanding of emotions and coping strategies left them uncomfortable with their own feelings, leading them to suppress emotions or label them as “good” or “bad.” Through the HEART© curriculum and EAL activities, they learned to tolerate and interpret their emotions rather than avoid them. This shift replaced previous tendencies to please others or conform to external expectations with healthier emotional expression. Another participant stated, “…before this program, I didn’t even realize I was burying my emotions and not talking nice of myself mentally.” As participants became more accepting of what they were thinking and feeling, they reported greater clarity and improved ability to engage constructively with others’ emotions. As one participant reflected, Thinking that this is what I really want and then having visual evidence in front of your eye that it’s not what you’re communicating at the very least is just a profound visualization of all the things that you’re working through on the inside.”

Treatment group participants consistently noted that the unspoken norms of medical training promoted suppressing emotions, being skeptical, and prioritizing performance over mental or emotional well-being. Many felt that meeting external standards, regardless of their internal emotional state, was implicitly valued. This contributed to the belief that emotions such as empathy were signs of weakness and could hinder academic success, professional advancement, and critical thinking. A participant noted, “I’m truly amazed at how much I’m leaning in this research study each week. It’s really helped to start changing my mindset for the better.”

Before the HEART© curriculum, participants described how their difficulty understanding and tolerating their own emotions made it challenging to empathize with themselves or others.

Participants shared that the HEART© curriculum empowered them to more fully tolerate and accept their emotions, shifting from avoidance to constructive engagement. Several described how developing this acceptance made emotionally complex interactions less overwhelming. One participant explained, “I could tell when I’d switched out of calm and bring myself back,” illustrating new confidence in recognizing and regulating emotional shifts. After learning to identify and understand their feelings, they reported becoming more comfortable engaging with others’ emotions as well. Another participant noted, “When the horse finally approached me, it felt like it really ‘saw’ me. Like it could tell I was being honest with myself,” reflecting how coherence deepened their sense of relational grounding.

This increased emotional acceptance also reshaped their understanding of professionalism. Learners described recognizing that emotional presence was not incompatible with competence and one participant summarized, “I realized emotions aren’t the enemy. They’re information.” Through HEART©, participants discovered that a physician can be both decisive and compassionate simultaneously and that embracing, not suppressing their internal states enabled more effective and authentic interpersonal engagement.

Participants reported an increased ability to engage right-brain processes such as creativity, intuition, and imagination during EAL sessions. As their learning progressed, many described developing a more effective balance between analytic and intuitive thinking, which they associated with greater emotional well-being and cognitive flexibility. Several explained that the HEART© coping strategies helped them remain centered in challenging situations, which enabled them to acknowledge and manage emotions without becoming overwhelmed. One participant noted, “it was a very insightful day for me because I’ve got to break past that habit of internalizing things, and that’s usually what then would lead to fermenting on emotions and causing physiological distress.”

Participants also described becoming more attuned to their internal states and more skilled in regulating them. Many recognized longstanding patterns of emotional suppression and reported developing healthier approaches to managing stress, fear, and self-doubt; skills they viewed as essential to their future clinical roles. Participants mphasized that HeartMath® coherence techniques provided practical, accessible tools for calming the mind and body during moments of heightened stress, and for enhancing their capacity for self-regulation in both educational and potential clinical environments. One trainee reflected, “It’s crazy how well the exercises work at clearing my mind and making decisions easier,” demonstrating increased confidence in their emotional regulation skills.

Participants described gaining greater emotional awareness and an increased ability to process their emotions constructively. They felt these changes directly strengthened their confidence and capacity for compassion. Many explained that learning to reflect on, rather than suppress, their emotions empowered them to respond more empathetically and address challenges more directly. One student noted, “During the exercises I felt more confident in myself. I was living in the moment and was relaxed.” A participant who was concurrently shadowing a physician in a free clinic shared, “I think it helped a lot with having a better presence with patients and how you influence them. Being more aware of my thoughts and then my actions and my nonverbal cues I think will be very important not just with patients but in life in general.” illustrating a shift toward viewing emotions as a resource in the clinic rather than a liability.

Participants also recognized that confidence plays a critical role in patient trust and professional identity. Several acknowledged that self-doubt had previously limited their ability to engage authentically with patients and peers. After completing the HEART© curriculum, students reported increased self-assurance and a stronger ability to focus on others. As one participant shared, “I just think the confidence building, the leadership, the goal setting is all going to be very positive for when I do become a doctor and when I have my own patients.” reflecting a move toward greater confidence in clinical interactions.

Equine activities further illuminated discrepancies between intention and action, prompting deeper reflection on PIF. Students described how the horses’ responses often revealed their internal emotional states. One participant stated, “The horse showed me when I wasn’t as grounded as I thought,” which encouraged them to cultivate greater alignment between their internal state (heart) and outward behavior. Collectively, participants reported feeling more grounded, confident, and connected to their developing sense of purpose in medicine.

Treatment group participants explained that the EAL sessions helped them better understand the power of emotions, the importance of coping skills, and the ways in which their interactions with horses mirrored their interactions with people. Working with the horses required them to confront their own emotions and intentions; as one student noted, “The horse mirrored what I was feeling. When it wouldn’t come near me, I realized I wasn’t as calm or open as I thought.” Learners described how horses either approached or avoided them depending on their emotional state, making the effects of emotional regulation immediately visible. Another participant shared, “If your heart doesn’t match our head, the horse will call you out on your B.S. ha ha!”

Participants recognized that their emotional energy influenced not only the horses but also the people they interacted with. Many drew parallels between equine behavior and patient behavior, acknowledging that, like horses, patients may not automatically cooperate and respond to a clinician’s presence, coherence, and clarity. Participants consistently described the horses as responsive, nonjudgmental partners whose behavior provided real-time feedback on leadership presence. They learned that horses responded not to verbal commands but to emotional congruence, intentionality, and nonverbal communication. As one participant shared, “The horses seem like they can sense everything. When you get in with the horses, if you don’t actually believe something you’re saying, they know. And it makes it so much more real.”

These experiences strengthened participants’ confidence in their ability to influence others through a calm, focused presence and deepened their understanding of relational leadership. One student reflected, “I was used to being told exactly what to do, and this helped me think for myself.” Participants noted that the integration of didactic instruction, biofeedback, and equine interaction made concepts such as resilience, emotional regulation, and leadership more concrete and applicable to clinical training. Many described these experiential components as more impactful than traditional classroom instruction. As one student explained, “You can change a lot more when you cut through everything, and that’s what the horses let you do.”

The integration of quantitative and qualitative yielded similar results. Physiological improvements in HRV and coherence aligned closely with participants’ descriptions of enhanced emotional regulation and greater calm. Similarly, increases in MSWBI scores were consistent with qualitative reports of reduced stress and improved well-being. Divergence in resilience trajectories between groups was echoed in participants’ narratives, as treatment group members described developing new coping strategies and a clearer sense of purpose. One student explained, “Practicing when I didn’t need it made coherence automatic when I did,” illustrating how regulation skills became accessible during high-stress moments. Taken together, these findings suggest that the HEART© curriculum supported both the physiological and psychological dimensions of resilience, and offered a holistic approach to well-being and leadership development in early medical education.