---
title: "FIERCE trial protocol: Remote Four Immeasurables meditation (BEST) for physicians with elevated st"
id: "plos-one-7-protocol-for-project-fierce-a-randomized-controlled-trial-to-evaluate-a"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-7-protocol-for-project-fierce-a-randomized-controlled-trial-to-evaluate-a"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906"
published_at: "2026-09-09T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# FIERCE trial protocol: Remote Four Immeasurables meditation (BEST) for physicians with elevated st
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-7-protocol-for-project-fierce-a-randomized-controlled-trial-to-evaluate-a
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906)
- **Published At:** 2026-09-09T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Nearly 80% of healthcare providers report adverse psychological symptoms tied to workplace stress; physicians face unique occupational stressors that increase risk for depression, burnout, sleep disturbance, and adverse occupational and patient outcomes. - The study tests a six-week, remotely delivered mindfulness program, Building Emotional Strength Training (BEST), based on the **Four Immeasurables** (loving-kindness, compassion, joy, equanimity) to reduce **perceived stress** in physicians. - This single-site, two-arm randomized controlled trial will enroll 90 full-time physicians and randomize 1:1 to BEST (n=45) or waitlist control (n=45); assessments occur at baseline, mid-course (week 3), and post-intervention (week 6). - Primary outcome is perceived stress; secondary outcomes include burnout, depressive symptoms, psychological well-being, sleep quality, and **inflammatory biomarkers**; exploratory aims examine mediators (compassion, positive affect, equanimity, mindfulness). - Recruitment is remote across healthcare systems; eligibility includes practicing physicians scoring ≥4 on the PSS-4; exclusions include regular meditation practice, prior Four Immeasurables training, and regular tobacco use. - Randomization used a pre-generated block sequence; allocation was not concealed through personnel separation and the trial is open-label; objective inflammatory outcomes and preregistered analysis plans aim to limit bias. - Assessments use self-report questionnaires delivered via Qualtrics and at-home blood collection kits mailed to participants; midpoint battery is abbreviated; baseline and post-intervention include the full measures and blood draws. - The trial is registered (ClinicalTrials.gov NCT07283744) and the analysis plan was preregistered on OSF; IRB approval was obtained from UCLA (IRB-25–1518) and reporting will follow CONSORT guidelines. - Recruitment began December 2, 2025, expected to conclude October 2026 with data collection through December 2026; results anticipated in early 2027. Specific laboratory processing and storage procedures for biological specimens were not fully reported in the source.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosone%2Farticle%3Fid%3D10.1371%2Fjournal.pone.0357906) * * About * Browse * Publish * [](https://journals.plos.org/plosone/ "PLOS One") * Search [advanced search](https://journals.plos.org/plosone/search) * [Browse Topics](https://journals.plos.org/plosone/subjectAreaBrowse) Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click [here](https://github.com/PLOS/plos-thesaurus/blob/master/README.md "Link opens in new window"). [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906) [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906) * 0 [Save](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906#savedHeader) * 0 [Citation](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906#citedHeader) * 34 [View](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906#viewedHeader) * 0 [Share](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906#discussedHeader) Open Access Study Protocol # Protocol for project FIERCE: A randomized controlled trial to evaluate a positive emotion-focused meditation intervention for physicians with elevated stress * J. Richard T. Korecki , Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing * E-mail: tkorecki@g.ucla.edu Affiliation Department of Psychology, University of California, Los Angeles, California, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-6074-2175 ](https://orcid.org/0000-0002-6074-2175 "ORCID Registry") ⨯ * Diana Winston, Roles Conceptualization, Methodology, Writing – review & editing Affiliation UCLA Mindful, UCLA, Los Angeles, California, United States of America ⨯ * Elizabeth Ko, Roles Conceptualization, Methodology, Writing – review & editing Affiliations Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, United States of America, UCLA Integrative Medicine Collaborative, Los Angeles, California, United States of America ⨯ * Sun Yoo, Roles Conceptualization, Writing – review & editing Affiliation Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, United States of America ⨯ * Joshua Khalili, Roles Conceptualization, Methodology, Writing – review & editing Affiliation Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, United States of America ⨯ * Julienne E. Bower Roles Conceptualization, Funding acquisition, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing Affiliations Department of Psychology, University of California, Los Angeles, California, United States of America, UCLA Jonsson Comprehensive Cancer Center, Los Angeles, California, United States of America, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, California, United States of America, Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience and Human Behavior, Los Angeles, California, United States of America ⨯ # Protocol for project FIERCE: A randomized controlled trial to evaluate a positive emotion-focused meditation intervention for physicians with elevated stress * J. Richard T. Korecki, * Diana Winston, * Elizabeth Ko, * Sun Yoo, * Joshua Khalili, * Julienne E. Bower ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: September 9, 2026 * * [Article](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906) * [Authors](https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0357906) * [Metrics](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357906) * [Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0357906) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pone.0357906) * [Abstract](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#abstract0) * [Introduction](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#sec005) * [Methods](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#sec007) * [Discussion](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#sec022) * [Conclusion](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#sec024) * [Supporting information](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#sec025) * [References](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#references) * [Reader Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0357906) * [Figures](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906) ## Abstract ### Introduction Nearly 80% of healthcare providers experience adverse psychological symptoms (e.g., depression, burnout, sleep disturbance) stemming from workplace stressors. Elevated levels of stress have been associated with unfavorable occupational, patient, and provider-related outcomes, imposing a heavy burden on a strained system. Given the impact of stress on both employee and patient health, effective interventions are urgently needed to reduce distress and promote well-being among healthcare professionals. Mindfulness-based interventions show promise for addressing these challenges. We developed a six-week, remotely delivered mindfulness intervention, the Building Emotional Strength Training (BEST) program, based on the Buddhist Four Immeasurables practice to cultivate the distinct emotional qualities of loving-kindness, compassion, joy, and equanimity. The present study aims to evaluate the feasibility and efficacy of a Four Immeasurables-based mindfulness intervention on perceived stress (primary outcome), burnout, depressive symptoms, and inflammatory biomarkers, while enhancing psychological well-being and sleep quality (secondary outcomes) in physicians. We will also investigate potential mediators of intervention effects, including compassion, positive affect, equanimity, and mindfulness. ### Method We will enroll 90 full-time physicians in a remote, two-arm randomized controlled trial with 1:1 allocation to either the meditation intervention or waitlist control. Participants will complete self-report questionnaires and provide blood samples at baseline, mid-course, and post-intervention to assess outcomes and mediators. ### Discussion The project aims to advance the study of mindfulness-based interventions that reduce distress and promote well-being through practices that cultivate prosocial and altruistic feelings toward oneself and others. While mindfulness interventions have gained considerable interest, none have specifically drawn from the Four Immeasurables practice to target loving-kindness, compassion, joy, and equanimity. This novel investigation could expand our understanding of practices that foster kindness and compassion to reduce distress in an at-risk population. ### Trial registration ClinicalTrials.gov [NCT07283744](https://clinicaltrials.gov/ct2/show/NCT07283744), registered on 2025/10/14. The Open Science Framework, registered on 2026/06/26. ## Figures ![Fig 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.g001) ![Fig 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.g002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.t001) ![Fig 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.g001) ![Fig 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.g002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.t001) ![Fig 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.g001) ![Fig 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.g002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357906.t001) **Citation:** Korecki JRT, Winston D, Ko E, Yoo S, Khalili J, Bower JE (2026) Protocol for project FIERCE: A randomized controlled trial to evaluate a positive emotion-focused meditation intervention for physicians with elevated stress. PLoS One 21(9): e0357906. https://doi.org/10.1371/journal.pone.0357906 **Editor:** Suzit Bhusal, National Trauma Center, NEPAL **Received:** March 17, 2026; **Accepted:** August 19, 2026; **Published:** September 9, 2026 **Copyright:** © 2026 Korecki et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Data Availability:** No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion. **Funding:** JRTK, DGE-2146755, National Science Foundation, JRTK, N/A, Bedari Kindness Institute, JRTK, N/A, Pat Tillman Foundation, The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. **Competing interests:** The authors have declared that no competing interests exist. ## Introduction Healthcare providers face a large number of stressful situations daily, which may increase their risk of developing adverse mental and physical health conditions [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref001)–[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref004)]. Downstream consequences of working in high-stress healthcare occupations include elevated levels of stress, depressive symptoms, and burnout. It is estimated that frontline healthcare workers, including physicians, experience higher rates than the general population of stress, depression [[3](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref003),[5](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref005)], and burnout [[6](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref006)–[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref009)]. These conditions have been associated with unfavorable occupational [[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref010)–[22](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref022)], provider [[23](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref023)–[28](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref028)], and organizational outcomes [[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref010),[17](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref017),[29](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref029)–[31](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref031)]. Among healthcare workers, physicians face a distinct constellation of stressors, including high decision-making and diagnostic burden [[32](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref032)], long and irregular hours [[33](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref033)], and a lack of organizational support [[32](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref032),[33](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref033)], that may not be fully addressed by interventions developed for the broader workforce. In addition to the occupation-specific outcomes associated with increased levels of distress, growing evidence suggests that stress exposure can influence physical and mental health-related outcomes (e.g., cardiovascular disease, diabetes, depression, etc.) by stimulating pro-inflammatory biology [[34](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref034)–[36](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref036)]. In fact, frontline healthcare workers experience high rates of physical complaints [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref001),[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref002),[37](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref037)–[41](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref041)] that may be due to elevated inflammatory activity. Additionally, elevated inflammation may adversely affect cognitive, emotional, and behavioral outcomes [[42](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref042)–[44](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref044)], further impairing healthcare providers’ effectiveness. Although much of the literature identifies organizational and structural factors, such as workload, administrative burden, and scheduling, as central drivers of physician stress and burnout [[33](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref033)], individual-level interventions may offer complementary tools that help physicians manage the distress these conditions produce [[45](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref045)]. To date, several attempts have been made to address psychological distress among healthcare providers using individual-focused behavioral interventions, with mixed results [[45](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref045)–[48](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref048)]. Given the encouraging effects of mindfulness-based interventions (MBIs) on various outcomes in diverse populations [[49](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref049),[50](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref050)], it is unsurprising that these interventions have been used to address the needs of healthcare workers. Recent reviews have investigated the effects of several MBIs on various outcomes in healthcare provider populations with mixed results. Meta-analytic data suggest that while Mindfulness-Based Stress Reduction (MBSR) has demonstrated beneficial effects on reducing experiences of anxiety, depression, and perceived stress, the intervention was not effective at reducing symptoms of burnout [[51](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref051)]. These results may suggest that the specific type of mindfulness practice may matter for addressing the distress physicians experience. Interventions drawing on diverse contemplative practices (e.g., loving-kindness and compassion-based) remain largely unexamined in this population. Because physicians face substantial time and scheduling constraints, remote delivery may also improve the feasibility and reach of such interventions [[52](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref052)]. One of the ultimate goals of many MBIs, including MBSR, is to familiarize participants with what it means to be aware (i.e., mindful). Thus, the practices included in the interventions are designed to strengthen one’s ability to recognize when their awareness has drifted from the present moment and how to bring their focus back to the here and now [[53](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref053)]. An intervention aimed at enhancing positive psychological states may be more effective at reducing distress in this population. One such meditation-based intervention is the Four Immeasurables, also known as the Brahmaviharas in Pali. The Four Immeasurables were described in the Fifth Century in one of the primary treatises on Buddhist practice, the Visuddhimagga [[54](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref054)], and include the distinct emotional qualities of loving-kindness, compassion, sympathetic joy, and equanimity [[55](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref055)]. These emotional states are gradually cultivated through specific practices that often include visualizing oneself and others and directing the feeling state of the particular component (e.g., loving-kindness) to one’s target by mentally reciting phrases such as “may you live with ease.” Although the Four Immeasurables have been practiced in traditional Buddhist settings for thousands of years, the entire four-factor program has not been investigated in a randomized controlled trial (RCT). Despite a shortage of trials investigating the complete Four Immeasurable practice, there is evidence from RCTs evaluating interventions that include singular components of the Four Immeasurables, as well as from cross-sectional studies demonstrating the benefits of experiencing kindness, compassion, joy, and equanimity. These investigations suggest that these practices and emotional states can beneficially impact psychological, social, and biological outcomes [[56](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref056)–[64](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357906#pone.0357906.ref064)]. Additionally, these four psychological constructs may be particularly beneficial in lessening the common occupation-related symptoms experienced by healthcare providers, namely perceived stress, depression, and burnout [[60](https://jo
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