A study of medical students’ experiences at Shiraz University of medical sciences from the implementation of integration in medical education: a qualitative study

Abstract

Background

The basic science course is the foundation of medical knowledge, and how and in what form the teaching of this course is a vital issue. A successful curriculum should include everything medical students need in their future careers. Basic science education should be such that students clearly understand the relationship between the content and its application in clinical practice. Therefore, the need to change the curriculum of the general medicine course, especially course of the Basic science, in content and layout in an integrated way is felt more than before. This study was designed to explain the experiences of medical students from the Shiraz University of Medical Sciences since the implementation of integration in 2020.

Methods

The present study was qualitative research with a conventional content analysis method. Participants were selected for the interview purposefully. They included 12 Medical students from basic and clinical sciences and 5 faculty members. Data were collected through semi-structured interviews and the content analysis method. Four methods of Goba and Lincoln were used to evaluate the accuracy of the data.

Results

After summarizing and analyzing the data, 221 codes were extracted. They were divided into seven subcategories and finally, three main themes including Enjoyable experiences (advantages of the integration system), Upsetting experiences (Disadvantages of the integration system), Resolutions to solving integration problems were extracted. Generally, the findings indicated a positive evaluation of medical students of Shiraz University of Medical Sciences from the integration system, and they stated that the integration causes an interaction between basic and clinical sciences and also increases students’ motivation.

Conclusion

The findings indicated a positive evaluation of Shiraz’s medical students of the integrated system. According to the results of this research, it can be said; that the use of integration horizontally and vertically in medical education improves the quality of education compared to traditional methods. The integration of basic and clinical science is important in the sense that can be a powerful tool for learning and acquiring skills, also, it can also help in the promotion of professional development of students and motivate them to study more in interactive manner and be loyal to lifelong learning. study generally showed that combining theoretical and practical courses has advantages and disadvantages, but its advantages are more. Paying attention to the shortcomings, especially in the supply of human resources and professors, and reforming the program with continuous revision are issues that education managers and medical educators of the general medical practice should address.

Background

The modern history of medicine begins with the Flexner intervention of 1910, which produced the dichotomous (preclinical/clinical) traditional medical curriculum [1, 2]. The dichotomous strategy led to the separation of basic sciences from clinical sciences, and it continues in some medical schools until now [3]. This gave birth to the innovative integrated curriculum, including defining integration [4]. The idea of “the integration ladder,” presented by Harden, is a useful tool for medical teachers to improve education in medical sciences [5,6,7]. Integration means combining content areas or subjects that are included in the curriculum in traditional educational systems separately and in isolation from each other [3]. The “Ladder of Integration” has 11 steps from subject-based curriculum to integrated teaching and learning curriculum. In the first four steps, the emphasis is on the subjects or disciplines: Isolation, Awareness, Harmonization, Nesting, Temporal coordination, Sharing, Correlation, Complementary, Multi-disciplinary, Inter-disciplinary, and Trans-disciplinary [4]. The integration ladder is a useful tool for the medical teacher and can be used as an aid in planning, implementing, and evaluating the medical curriculum [8].

Some advantages of integration are: reducing the fragmentation of course parts and creating unity and communication between disciplines, increasing student motivation, more effective teaching, and raising the level of educational goals (improving the level of knowledge retention to the level of its application and problem-solving skills), the communication and cooperation of professors, the rationalization of educational resources, increasing self-confidence, positive attitude, and ability in learning. Of course, the integration program also has disadvantages based on the studies conducted, such as not fully covering the content and basic principles of a field, unintentionally omitting some topics, professors’ less proficiency in integrated education compared to the traditional one, and higher cost [9,10,11].

Recent evidence in Iran and other parts of the world shows that we can improve the medical school curriculum by integrating basic and clinical sciences [10, 12,13,14,15]. Ebrahimzadeh et al. (2021) evaluated the effectiveness of Integrated Teaching on Students’ Learning by a quasi-experimental study in the infectious disease ward. The integrated teaching approach was adopted in the intervention group by four professors of epidemiology, microbiology, infectious diseases and pharmacology. The results reveal that the integration of basic and clinical subjects helps medical students to better comprehend the pathophysiology of diseases and increases their satisfaction [13].

Rosenberg and Hartley (2024), in a mixed-method study titled “Continuity of Changed Attitudes Among Students in an Integrated Anatomy Curriculum” in the United States, asked students about attitude changes in the anatomy course. The results showed the persistence of specific attitudinal differences between groups with blocked anatomy versus integrated anatomy in learning anatomy and confidence in this learning [14]. In the book A Practical Guide for Medical Teachers, Harden explained the importance of adding social sciences to the curriculum of medical schools and emphasized that social and behavioral sciences in medical school curricula are core subjects in medical education, and they should be integrated into different courses [15].

In the traditional medical education curriculum at Shiraz University of Medical Sciences (SUMS), subjects were taught as separate and independent packages, with an emphasis on basic sciences in the first years and clinical experiences in the later years. This separation hindered understanding the contents and creating connections between basic and clinical sciences. One of the solutions offered to address the lack of connection between the different parts of theoretical courses and the real field of medicine is the horizontal and vertical integration of basic and clinical courses, which has received special attention from the Ministry of Health in recent years [16].

The integrated program at Shiraz University of Medical Sciences includes the horizontal integration of basic science courses and 36 months of rotation in clinical departments, which started in 2009 [15]. Since improving quality is one of the basic goals in higher education worldwide, the evaluation of higher education cannot rely solely on quantitative indicators but must also be comprehensive, containing both quantitative and qualitative criteria and internal and external evaluation. Although the positive and negative impacts of this program have been expressed through the quantitative study of Ruhal Amini and colleagues using the CIPP model, we are not aware of the deeper opinions of the students who have experienced this program [17].

Objectives

In this study, we aimed to identify the themes that explain medical students’ experiences at Shiraz University of Medical Sciences regarding the implementation of horizontal and vertical integration of basic medical sciences in sharing levels in medical education. Additionally, we aimed to develop a conceptual framework to explain the challenges and problems through the perspectives of both students and professors.

Methods

Design

The current research is a qualitative research of the conventional content analysis type which was conducted on Shiraz medical students with integration experience in 2020. The present qualitative research, through semi-structured interviews, examines the experiences, meanings, understanding, and interpretations that the participants have about the implementation of integration in medical education, and explores new perspectives and concepts of its implementation [18, 19].

Setting

This study was conducted at Shiraz University of Medical Sciences (SUMS). The university currently includes more than 10,000 students, 200 majors, 782 faculty members, 54 research centers, 13 educational hospitals, a history of 70 years [20].

Participants and sampling

The statistical sample included 12 general medical students and 5 medical faculty professors in basic and clinical sciences. The participants were selected as a targeted sampling of students with maximum variation in terms of the academic semester and academic level, and sampling continued until data saturation when no new code was attained during interviews and repetition of the previous categories and codes.

Accordingly, we selected 12 medical students from year 1 to senior interns and 5 faculty members (FM) within a wide range of academic rank from shiraz Universities of Medical Sciences in 2020 and 2024. The inclusion criteria for students were: completion of the informed consent form, medical students, interested in participating in the research, allocating time for interviewing and reviewing the material, and the exclusion criterion was, not being satisfied with participation in each stage of the study. The inclusion criteria for faculty members in the medical education field were a minimum of ten-year teaching experience. The exclusion criterion was the unwillingness to participate in the study.

Initially, we collected data from a medical student well known for his effort in learning; then, we continued data gathering from the other students, faculty members, and medical education experts until data saturation was obtained and when no new code was attained during interviews and repetition of the previous categories and codes [18, 21].

Tools/instruments

After obtaining permission from the university and coordinating with the participants, the researcher collected information at the medical school, including the library, teaching halls, sports field and coffee shop in Shiraz University of Medical Sciences were conducted as the research environment. The environment of conducting qualitative research is the place where the experiences of the people in question take place. In this study, the main method of data collection was structured individual interviews. The interview queries focused on participants’ experiences of integration implementation in medical education. The interviews started with questions as follows: What is your description of integration in medical education? Tell me about your experiences in integration in bacic or clinical sciences and diferent situations, including the classroom, laboratory and clinical setting. According to the contributors’ answers, we asked probing questions and duo to the results we added FM in research. Each interview took 20 to 60 min, with an average of 35 min. Data were collected and analyzed using Microsoft One Note 2010, Microsoft, Redmond campus, US. We listened to each recorded interview to get an overall understanding. In order to keep the information and data confidential, any names were avoided in the interviews and conversations were recorded, and each person was assigned a specific code, and all information was kept confidential.

Data analysis

The applied qualitative content analysis approach was conventional. The purpose of content analysis in this research is to provide knowledge and understanding of the concept of integration or to provide knowledge, a new insight, a picture of reality, and guidance for the practice of integrating courses in the Shiraz Medical School.

The conventional content analysis is usually used in the design of studies whose purpose is to describe a phenomenon. Therefore, through induction, categories emerge from the data [18]. Data analysis was performed simultaneously with data collection. In this process, the data were divided into the smallest units of meaning. New data were compared for similarities and differences and classified through repeated reviews and merging of similar data. The obtained data were evaluated using conventional content analysis using the approach of Graneheim and Lundman, (2004) [22]. The data were qualitatively analyzed in five steps, including (1) transcribing the entire interview immediately after completion, (2) reading the entire text to reach an overall understanding/summary of the content, (3) determining meaning units and primary codes, (4) Categorizing similar initial codes into more comprehensive categories and (5) determining the main theme of the categories.

In other words, the information collected from the interviews was analyzed through association of meaning. In this way, the data analysis started by reading them repeatedly to get a complete understanding of them. Then, based on his perception and understanding of the studied text, the researcher started writing the preliminary analysis to create a background for the emergence of codes. This action caused the design of codes to emerge from the text. In other words, the meaning unit was determined step by step, and its compression continued until the code was determined. Then the codes were categorized based on their similarities and differences. This categorization was created by organizing and grouping codes into meaningful clusters [19]. In the following, considering the quality of communication between subcategories, the researcher was able to combine and organize subcategories to turn them into fewer categories (categories). In other words, the general concept that was the result of summarizing these categories (theme) was obtained. To maintain reliability, the content was reviewed in two stages, one after 10–50% of the categorizations were completed and the other at the end of the work.

Rigor and trustworthiness

Four Guba and Lincoln methods were used to confirm the correctness of the data. These validation criteria are; Credibility, Transferability, Dependability, and Confirmability, which are observed in this study as follows [18, 23]. For the validity of the study, various methods such as long-term engagement, continuous observation, triangulation, asking colleagues, and member checks were used. The researchers’ effort was to create an intimate and reliable space between the researcher and the participant to strengthen and enrich the data. It was the revision of supervisors, using the supplementary comments of colleagues (peer check) and the review of manuscripts by participants (member check), that the reform was done and suggested points were added and actions were taken to increase the validity of the research.

Transferability means the ability to generalize the results obtained from the interview sample to the entire population [18, 24]. In this study, we tried to describe all the details of the research, from sampling to collection and complete analysis, so that there is no ambiguity about transferability. In the current research, an external observer who was experienced in qualitative research was used, who examined and confirmed the basis of the analysis process, and as a result, the reliability of the research was obtained. The last thing is related to the ability to study. That is, the sources taken from it can be assured that the conclusions and interpretations made are directly related to them [23]. The external observer had access to things such as: interview tapes, executed texts, notes, analyzed data, study findings, extracted meanings, codes, themes and classifications, details of the study process, the initial intention of the study, the initial proposal, Interview questions and all study details, that, in addition to reliability, also helped the verifiability of the research. See the strategies used in the rigor and trustworthiness section in Table 1.

Table 1 Strategies for meet the Four Guba and Lincoln Criteria

Results

The demographic characteristics of the study participants are shown in Table 2.

Table 2 Demographic characteristics of the study participants

After analyzing and summarizing the information, about 221 propositions were extracted. These propositions were converted into seven categories, and finally, among them, the following three main and central themes emerged (Table 3).

Table 3 Theme and subthemes extracted from codes

According to the participants, enjoyable experiences was the most of the student’s and faculty members expericees from the implementation of integration in medical education. The educator and the student in this process, act rationally and intentionally and are aware of the factors that make the in tegration of curriculum enjoyable or upsetting them.

Theme 1: enjoyable experiences

Based on the experiences of the students and faculty members participants, they had enjoyable experiences in the implementation of the integration plan, which were divided into two main parts. Students say that the large volume of courses has been reduced due to non-repetition of materials in different courses, and also, the pressure and strictness of basic sciences curriculumin has been reduced. They have experienced the joy of group work in classrooms and better understanding of course materials with the presence of two professors. Creativity and mental preparation for performing future medical tasks by examining clinical cases in vertical integration was one of the benefits of implementing the integration plan.

The professors also expressed their pleasant experiences in dividing responsibility in different subjects in the compilation of textbooks, being aware of the experiences of colleagues in other educational groups, and holding interactive classrooms instead of the traditional and dry classroom. According to them, the integration method saves time and avoids repetition of material in different courses. One of the students said in this regard: “…, I enjoyed when the professor of surgery explained the problems related to abdomen together with the professor of anatomy and asked various questions to us (for example, they said, who has experienced pain witch related to appendix? How was it, come and show me).”(Student no. 4) students’ experiences: Students believed that teaching basic sciences together with clinical education is one of the best learning methods. Their attitude towards basic science courses was that they were ineffective and unnecessary in their future careers and had created a negative attitude in them, but they acknowledged; that the integration of theoretical and clinical courses can help to meet the needs of the general practitioner and the student can gain more skill in medical knowledge. Therefore, regardless of how the program was implemented, most students believed; that the content of the combination of courses could create continuity in the mind and increase self-confidence and a better attitude toward the integration program. In general, students’ attitude toward integration was positive. One of the professors said in this regard: “.I have seen that when we explain different materials from a clinically important aspect or when I explain the reason for conducting biochemistry experiments in physiology, they(the students) see how anemia causes hypoxia. Students listen with interest and participate in discussions…” (FM no. 7).

Interaction between basic and clinical sciences: Students supposed that basic science courses were forgotten in the following years of study. Therefore, basic science education along with clinical science education and bedside exposure in teaching hospitals can help in deeper learning of basic science. They expressed that integration causes an interaction between basic and clinical sciences and creates subject harmony in the student’s mind. Students considered the interaction between basic and clinical sciences to facilitate learning and a deeper understanding of the material and improve their knowledge.

Increasing students’ motivation: Students believed that the implementation of an integration program motivates them to participate more in academic discussions, and if the program’s objectives are explained to them at the beginning, it has a greater impact on increasing motivation. Ultimately, proper implementation of the integration program can prepare students to provide appropriate treatment and comprehensive, community-based care. An example of the statements of one of the student regarding interactive education:

“…This system is much better than trying to examine the tissue completely or read the anatomy all at once and…”(Studentno.2).

The advantages of integration: From the student’s point of view, these advantages are: “Presenting all the materials related to any subject does not confuse the person’s mind and gives a better understanding of the subject. The course of physiopathology, also makes students able to understand almost the entire pathology, pharmacology, and epidemiology of the subjects. Understand better and in more time, and there is no evasion. The integration system creates more interest and desire to study in students. Students will become more oriented, especially when they are interns. In this case, the student can more easily read the section. (Studentno.9)

“…It covers simply and has a better clinical view, and in practice, it works stronger. Presenting clinical cases together with theoretical topics makes for a deeper understanding of the material…”.

An example of one of the students statements in this regard; “…This feeling of responsibility that slowly rises in the guard is very good! Because it happens after the studentship and before the internship and not suddenly and all at once during the internship…”(Studentno.3).

Or student number 1 said; “Presenting all the materials related to the subject of the course makes a person gain a better understanding of that subject and in the course of physiopathology, it makes people able to read and understand almost all the topics of pathology, Pharmacology, and epidemiology better and in more time, and there is no evasion of material…“(Studentno.1).

Theme 2: upsetting experiences

In the current study, based on the experiences of students and professors, they were dissatisfied with some of the problems and considered them to be disturbing problems in the implementation of the integration plan, which are classified into two main parts: the lack of preparation of the structure, including the deficiency of human resources, especially professorslack and problems related to the implementation of laws and guidelines.

Irregular attendance of clinical professors, non-revision of comprehensive textbooks in some courses, inadequacy of questions in some exams with course volume, inadequacy of course grades, non-observance of priority and lateness of courses were among these challenges.

The long time spent by 6th-year medical students in the clinical departments of hospitals destroys the student’s study time. Places too much value on some courses in basic sciences, when they are not very practical. Clinical professors’ use of a large number of Power Points and the use of terms that are not familiar to students in education, and little access to suitable books for integration. An example of students;

“…One of the disadvantages of this system in the basic sciences is that, for example, if those subjects are presented together in the nervous system, anatomy, tissue, embryo, and physiology, during the exam, the grades are all taken into account, so most of the middle school students. They can use this escape route and escape from those units that have more difficult anatomy and pass that unit with the physiology score and do not read the contents completely…”(Studentno.5).

Theme 3: resolutions to solving integration problems

Provision of a suitable physical space for the implementation of the plan, considering the density of theoretical and practical courses at the beginning of the academic semester, solutions related to the additional facilities of the implementation of the plan, increasing the number of faculty members of the groups involved in the implementation of the plan, holding an annual conference and sharing the experiences of the professors involved in the integration plan across the country and revision the plan based on the experiences of expert professors can have good results. Based on the experiences of some professors from this plan and their confusion, the insufficient number of professors to implement the plan to reduce the efficiency of professors due to the density of courses at the beginning of the academic semester should be compensated by employing new professors and completing the educational curriculum.

Presentation of common cases alongside theoretical contents: From the point of view of students, the simultaneous presentation of theoretical materials and clinical cases can greatly help to increase internal motivation and improve the students’ perspective towards basic science courses, and the use of practical educational activities, laboratory activities, as well as new teaching and learning methods such as drawing pictures and watching videos in Increasing the power of memorization of learned material is effective in students and should be paid attention to by teachers of basic sciences.

Also, increasing practical and laboratory works in terms of the quantity and quality of teaching cases, increasing the number of training sessions, presenting more clinical materials and reducing memorization materials, the professor’s use of new tools for teaching and its non-uniformity (for example, more use of educational videos, use of mock-ups, more education with photos), student-centered education (questions and answers in class and participation of students in discussions), simultaneous presentation of course materials by clinical and basic science professors and more mastery of the professors on the materials, as well as providing courses online can be more effective in Create an integration system.

Student participation in designing and revising the curriculum: Based on the experiences of professors and students, using the opinions and experiences of students can help in upgrading and revising the curriculum. Better interaction and participation of students in designing and revising the curriculum solves integration problems better. Students stated that if specific points of reference are prepared by professors for a specific clinical stage or a book that students only refer to, more effectiveness and learning will be achieved in the integrated system. one of the students said: “.It would be much more useful if the professors would come to a consensus and prepare a book or a pamphlet, or specify some reference material so that only those parts should be read. Or “References are heavy for a student who has just entered the clinical stage and just got rid of basic sciences, and practically no one can and does not have time to read references for exams!.”(Studentno.4).

Discussion

The present study was conducted to explain the experiences of medical students from integration in the general medical course of Shiraz. According to the participants, enjoyable experiences was the most of the student’s and faculty members expericees from the implementation of integration in medical education. This result in line with Shojaei et al. (2022) in the blacksmith approach, a strategy for teaching and learning in the medical anatomy course wich the students were satisfied with the presentation of anatomy lessons in the integrated system [25]. Also the study of Dehghan et al. (2017) in Early clinical exposure program in learning renal physiology revealed that the students were satisfied with this vertical integration [26]. These two studies show the satisfaction of students in one course, while the results of the present study are related to the whole integration system in the education of medical students.

One of the topics of this research was interactive education. Research at Isfahan University of Medical Sciences showed that the integration of practical and basic topics in the bacteriology course has led to a change in students’ attitude towards this course as a useful and practical unit so that they feel the need to pass this course more [27].

Other studies related to anatomy and physiology courses showed an improvement in students’ attitudes towards these courses after the implementation of the integration plan [28, 29], and the above results are consistent with the findings of this study. The results of the present study showed; that the interaction between basic and clinical sciences can help to learn more deeply about basic sciences. Boon’s study showed; that the lack of connection between basic and clinical sciences can discourage students from studying basic science courses [30]. Baghdady also showed in research that teaching basic sciences along with clinical sciences to dental students is more effective than teaching basic sciences alone [31], and the results of this research are in line with the findings of the present study.

According to the results of this study, the implementation of integration encourages students to participate more in course topics and has a greater effect on increasing their motivation. In his study, Khazai concluded that being in the hospital and dealing with the patient, at the same time as teaching theory, can greatly help to increase students’ motivation [29]. The results of Dehghan’s study about early clinical exposure showed that most medical students believed that this exposure increased their motivation to study basic science courses [26]. The results of the studies by Knowlton and Roholamini about the integration of basic sciences with clinical courses respectively showed that students found more enthusiasm for studying, and the integration plan encouraged them to participate more actively in class [32, 33]. Integration was found to be a factor in increasing students’ motivation.

Another topic of this study was the advantages and disadvantages of integration in the field of medicine. From the point of view of students, integration will have many benefits such as creating an attractive and effective educational environment for professors and students, and will lead to the satisfaction and personal development of students. It also has advantages such as; mental coherence about the material, creating more interest and desire to study with students, and making students more oriented to enter the departments and understand the material more deeply. Among the disadvantages of the integration plan from the students’ point of view, we can mention things such as: “giving high value to some courses in the basic sciences while they are not very practical and lack of access to suitable books for the integration plan.”

Jalilian’s study also showed that regarding the integration program of the physiopathology course, due to the benefits of integration, such as increasing students’ motivation in learning courses, improving the educational level from memorization to application, increasing communication and cooperation between students and professors, and rationalizing the process of educational resources, It is also appropriate to continue the process of integration in other periods that have not yet started integration [34]. Rahman also showed; that the complete integration of basic science courses for medical students promotes educational goals and facilitates learning [35]. Kasarla’s study revealed that integrating the curriculum of medical and dental students leads to a range of positive outcomes, including enhanced interdisciplinary collaboration, improved clinical reasoning skills, and increased student satisfaction [36]. Also, Sethi’s study findings reveal that curriculum integration offers numerous benefits, including enhanced student engagement, improved critical thinking skills, and a more holistic understanding of interconnected knowledge domains [37]. The results of the mentioned studies are consistent with the findings related to the advantages and disadvantages of integration in this research.

The results of the present study showed that the students positively evaluated the effect of presenting clinical cases in classes and stating references on their level of preparation before entering the hospital, and they believed that the theoretical content and clinical cases at the same time can help a lot to increase the internal motivation and improve the perspective of the students at compared to basic science courses. In Kumaravel’s research, the integration of the medical curriculum, its review, and its use before clinical exposure, increased students’ knowledge and skills [38]. The study findings of Husain & et al. underscore the importance of integrating various disciplines, such as basic sciences, clinical knowledge, and professional skills, to create a comprehensive and cohesive medical curriculum. The research findings demonstrate that integrated curricula facilitate a deeper understanding of the interconnectedness of medical disciplines, allowing students to develop a holistic approach to patient care. By integrating basic sciences with clinical knowledge, students gain a more comprehensive understanding of disease processes and are better equipped to make informed clinical decisions [39]. In another study by Schmidt, the results showed that those students who are trained with the integrated program and presenting clinical cases simultaneously with theory have better diagnosis and more favorable learning outcomes than the students trained in the traditional program [40].

Cowan’s study also showed that the integration plan is very useful, but there are not enough suitable books for the integration plan of courses [41], and the results of this research are in line with the results of this study. In medical education, the most important aspect of learning is the relationship between theoretical and practical knowledge, and integration is an important educational strategy in this field [7]. Wijnen-Meijer & et al. showed in their study by integrating basic sciences with clinical knowledge, students develop a deep understanding of the underlying principles of medicine and are better equipped to apply this knowledge in diagnosing and managing patient conditions [42]. In many courses, the integration of basic and clinical sciences has helped students to better understand the material, and if the teaching of basic science is such that students clearly understand the relationship between the material and their application in clinical practice, the material will remain in their memory better [16].

Revolution in medical education especialy in curriculum area is a global problem, and many medical schools have supposed investigation and experienced some intervention such as horizontal and vertical integration [43, 44]. Similarly, an active and integrated curriculum for teaching and learning medical students has been emphasized in all aspect of curriculum.

The strengths and limitations of the study

One of the strengths of this study is to consider the integration in general (horizontal and vertical) and about all courses (like some studies, it is not focused only on one course). All medical students from different levels: basic science, physiopathlogy, extern and intern were present in this study, and this diverse spectrum added to the richness of this study. The another strength from the participants perspective was: the applicability of students learning experiences and faculty members’ teaching experiences in the context and workplace conditions was one of the factors that changed the view of anatomy as an introductory course in medicine. As this study was conducted in one medical school, it is suggested that more studies and insights should be obtained from other participants to increase the generalized findings. Also, additional work should be done to be responsible for more practical guidance in the educational system regarding the horizontal and vertical integration.

Lessons learned and implications for policy-makers and future researchers

Managers, practitioners, and professors can use the elements of integration strategy to increase the effectiveness and productivity of medical education, by improve students’ and attitudes, knowledge, and skills. Since the integration in Shiraz University of Medical Sciences has progressed to stage 6 (Sharing) according to Harden’s ladder, it is recommended to provide a proper planning and platform for the implementation of other stages and then the researchers do research on these remaining steps. On the other hand, it is suggested to plan implementation of integration for other educationsl fields. also implementation of integration about the common interdisciplinary topics is suggested.

Conclusion

In this study, three central themes were extracted under the title: Enjoyable experiences (advantages of the integration system), Upsetting experiences (Disadvantages of the integration system), Resolutions to solving integration problems. In general, the findings indicated a positive evaluation of Shiraz’s medical students of the integrated system. According to the results of this research, it can be said; that the use of integration horizontally and vertically in medical education improves the quality of education compared to traditional methods. The integration of basic and clinical science is important in the sense that can be a powerful tool for learning and acquiring skills, also, it can also help in the promotion of professional development of students and motivate them to study more in interactive manner and be loyal to lifelong learning. study generally showed that combining theoretical and practical courses has advantages and disadvantages, but its advantages are more. Paying attention to the shortcomings, especially in the supply of human resources and professors, and reforming the program with continuous revision are issues that education managers and medical educators of the general medical practice should address.

Based on the constructivism theory Integration is an important part of SPICES strategy to improve learning and teaching in medical education. The best learning happens when there is a connection between new information and previous knowledge, and students are encouraged to integrate the new knowledge learned with previous knowledge and apply theoretical knowledge in clinical situations, even to solve the problems wich they have not been trained.

Also, It is suggested that to familiarize students with the process of integration, workshops should be held and the facilities of the dissection and mollage hall should be reviewed for integration. According to the educational goals of the integration plan, relevant books and lesson plans should be prepared and placed at the disposal of the students, and in the field of prioritization and precedence and backwardness of the courses, the order of presentation of the courses with the priority of histology, embryology, anatomy, and physiology should be regulated.