Background

Medical sciences and healthcare services are interconnected fields that significantly improve society’s health and overall quality of life. Medical education focuses on training competent healthcare professionals across various disciplines, while healthcare services aim to deliver therapeutic and preventive care to individuals and communities. Together, these domains form fundamental pillars of the healthcare system (1).

Integrating medical education and healthcare services involves coordinating and collaborating on the theoretical and practical aspects of these two fields to enhance efficiency, effectiveness, and quality in both sectors. The specific form of integration varies across countries, shaped by their cultural, structural, political, and economic contexts. In Iran, the integration process began with the establishment of the Ministry of Health and Medical Education (MoHME) in 1985 and was further solidified by the enactment of the law establishing medical universities in 1988 (2).

As the most revolutionary organizational movement, integrating medical education and healthcare services has significantly transformed the decision-making, management, responsibilities, and operations of these two entities over the years (3).

Integrating medical education and healthcare services in Iran is considered a unique and successful model worldwide. The evaluation of this integration extends beyond national boundaries, with respected international medical education authorities, including the World Federation of Medical Education and the World Health Organization, acknowledging and recognizing its merits (4-6).

The World Health Organization Regional Office for the Eastern Mediterranean has recognized the Iranian national health system as an unparalleled model for regional health ministries and authorities. Consequently, some countries in the region, such as Saudi Arabia, have established medical universities affiliated with their Ministries of Health, inspired by the Iranian integration model (7).

Positive achievements of this integration include balancing knowledge production with its application, strengthening the active role of medical universities in high-level health system decision-making, achieving equitable access to healthcare services, rapidly absorbing medical graduates into the healthcare workforce, making significant advancements in medical education, conducting practical research, enhancing technological innovations, and elevating the scientific and international rankings of these universities (2, 8).

However, despite these achievements, the integration of medical education and healthcare services in Iran continues to face several challenges, including a lack of focus and clarity in policy-making and planning, inadequate coordination and interaction among various levels of authorities within the healthcare system, the absence of common standards and quality criteria for evaluating medical universities and healthcare centers, an imbalance between the demand for and production of healthcare professionals in diverse medical fields, insufficient consideration of community opinions and needs in designing educational curricula, and the inability to effectively address emerging challenges such as infectious disease pandemics, demographic changes, and technological advancements (3).

Therefore, a comprehensive analysis of these challenges through content analysis can contribute to a better understanding of the indicators, achievements, challenges, and opportunities associated with integrating medical education and healthcare services in Iran. Qualitative content analysis involves extracting specific codes from texts or speeches by categorizing words and identifying similarities, differences, and relationships.

Objectives

This study aimed to conduct a content analysis of the 7th National Conference on the Integration of Medical Education in the Healthcare System in Iran to identify the indicators, achievements, challenges, and proposed solutions from the stakeholders’ perspectives.

Methods

Study Design: The present qualitative study was conducted in 2022. Qualitative content analysis was used to scrutinize the speeches delivered at the 7^th National Conference on Scientific Authority, themed “Integration of Medical Education in the Healthcare System: Achievements and Manifestation of the Scientific Authority of the Islamic Republic of Iran.” The study adopted a purposive sampling approach, commonly used in qualitative research.

Participants: The inclusion criterion for participation was a background in either implementing or policymaking in the integration of medical education within the healthcare system of the Islamic Republic of Iran. A comprehensive analysis was conducted on the speeches presented by 13 prominent thought leaders and contributors in the field of integrating medical education into the healthcare system. Table 1 presents the characteristics of the participants in detail. The study data were meticulously gathered directly from the experiences shared by the conference speakers. To unearth the insights, an inductive approach was adopted by our research team, culminating in the identification of codes, categories, subcategories, and overarching themes. These findings encapsulate the tangible experiences and perspectives of the individuals involved in this study. The data collection process unfolded throughout 2022.

Table 1. Characteristics of Participants

Data Collection: Our data collection strategy encompassed the execution of semi-structured and in-depth individual interviews from the outset, supplemented by the diligent maintenance of extensive field notes. The interview process continued until data saturation was reached, ensuring that all pertinent information for the conceptual framework under examination had been captured.

The duration of each presentation varied, ranging from 20 to 40 minutes, depending on contextual factors. Prior to each lecture, explicit consent was obtained from each presenter to record their speech, and subsequently, the presentations were transcribed onto paper at the end of each session. At this stage, the speech transcripts underwent multiple thorough reviews to allow the research team to develop a comprehensive grasp of the content. The primary researchers diligently listened to the speeches until they achieved a nuanced understanding of the central themes and primary concepts conveyed. Any uncertainties or ambiguities were promptly addressed through direct communication with the speaker immediately following the presentation.

Data Analysis: To analyze the data obtained from our study, the qualitative content analysis method was employed, following the framework outlined by Graneheim et al. (9). Initially, specific units were identified. In the context of our research, each lecture served as the primary unit of analysis. Subsequently, we defined meaningful units, which comprised expressions drawn from the speakers’ statements concerning various aspects of the core concept. We then further synthesized related meaningful units, leading to the development of research codes (10). Through an examination of the semantic distinctions and commonalities among the extracted codes, as well as quantifying them, the content of the interviews was systematically categorized into multiple levels of themes and subthemes. These categories underwent iterative reviews and were consolidated into overarching themes expressed through generalizable phrases and concepts (11).

Trustworthiness: The Lincoln and Guba criteria were employed to ensure the robustness of our data. These criteria encompass credibility, dependability, confirmability, and transferability, all crucial for rigorous research in the field of medical education. To bolster the credibility of our findings, our sampling strategy was meticulously designed to maximize diversity. During the lectures, several measures were implemented, including allocating ample time for data collection, maintaining a strong rapport with the speakers, and documenting notes while recording the data throughout the research process. In pursuit of data credibility, a three-fold triangulation approach was adopted. This involved engaging a seasoned team of qualitative researchers who diligently interacted with the emerging concepts over an extensive five-month period. The dependability of our data was assured through both peer reviews and external assessments conducted by our supervisors (12). We presented initial findings in the form of codes and categories to selected speakers, incorporating their valuable feedback. Furthermore, segments of the lectures were independently analyzed by colleagues not directly involved in the study, adding an extra layer of validation (12).

To ensure conformability, external evidence from other relevant studies was documented and integrated with the perspectives and insights of fellow researchers, reinforcing the credibility of our study’s findings. Finally, to enhance the transferability of our results, a comprehensive exposition of the concepts, the profiles of the speakers, the methodologies employed in data collection and analysis, and the inherent study limitations was provided. This information is intended to facilitate the replication of our research process by other scholars in the field of medical education.

In adherence to ethical principles, study participants were extensively briefed on the data collection procedures, research objectives, and the study’s nature. Participants were granted the autonomy to participate voluntarily or withdraw as they saw fit. We stringently upheld the confidentiality of information in a secure environment, preserving the anonymity of all involved. Consent for audio recording was obtained from the speakers, further reinforcing our commitment to ethical standards.

Results

Based on the discourse analysis of speeches delivered by 13 experts and practitioners in the field of integrating medical education into the healthcare system of the Islamic Republic of Iran, three primary themes emerged: achievements and opportunities, challenges and obstacles, and strategies for enhancing the integration plan. In the following sections, these themes will be elaborated upon in detail. In this study, three themes, eleven categories, thirty-four subcategories, and 310 initial codes were extracted (Table 2).

1. Achievements and Opportunities of the Integration Plan

Based on the analyzed speeches, the achievements and benefits of the integration plan can be categorized into five domains: educational, research, service, social, and economic:

1.1 Educational Achievements: According to the discourse analysis, the educational achievements of medical education integration include the following:

• Enhancement of the quality and quantity of
  medical education aligned with societal needs
  and health indicators:

“Today, we observe that among the countries sending the most medical students to our country are Pakistan, India, and Iraq. Currently, we have international students from 5 continents and
54 countries in our country.” (Speaker 1)

“In terms of quality, our medical education is now internationally endorsed. The World Federation of Medical Education has entrusted the accreditation of the medicine programs in the country to the MoHME. Consequently, when our medical students graduate, their qualifications are globally recognized for their quality.” (Speaker 4)

• Building self-confidence and scientific authority:

“The scientific authority they talk about is real, and today our physicians are accepted worldwide, and many of our professors who used to work in Tehran and major cities are now also considered university professors in the United States, doing the same job.” (Speaker 2)

• Addressing the shortage of faculty members and expanding medical universities across the country:

“We have 21,000 faculty members in various fields of basic and clinical sciences.” (Speaker 4)

Table 2. Themes, Categories, Sub-categories, and Codes Extracted from Interviews

1.2 Research Achievements: The research achievements of the integration plan include the following:

• Increased quantity and quality of research projects, publications, books, and research theses:

“In 2018, 34.6% of the country’s indexed scientific production was from medical universities, which have reached 39.7% in 2022.” (Speaker 3)

• Enhanced quantity and quality of projects, products, technologies, and innovative services:

“Robotic and surgical achievement include the single-photon emission computerized tomography (SPECT) heart device at Tehran Heart Hospital. We also have a domestically produced preclinical positron emission tomography (PET) scan device that Germany has sought to purchase, and shortly, a clinical PET scan device will also be produced.” (Speaker 5)

• Increased research activities, inventions, and preventive and corrective medical services:

“Shortly, six COVID-19 vaccines were produced in the country.” (Speaker 4)

1.3 Service Achievements: Service achievements of the integration plan encompass:

• Improved access to healthcare services in remote areas, especially underserved regions:

“Training female specialists in obstetrics and gynecology or general surgery and their appropriate distribution throughout the country for better care of women’s health.” (Speaker 6)

• Eliminating the need for foreign doctors and introducing the Islamic Republic of Iran as a model in the integration field:

“Before the revolution in Iran in 1979, many Pakistani and Indian doctors were active in the country and could not communicate properly with patients. However, now we have over 250,000 students studying in various fields of medical sciences in 68 medical universities. We also have 150 specialized and subspecialty fields; thus, there is no need for anyone to go abroad to study, especially in clinical fields.” (Speaker 4)

• Increased collaboration with domestic and international organizations and institutions in healthcare services:

“In terms of treatment, the quality is such that patients from neighboring countries come to our country for their treatment.” (Speaker 4)

1.4 Social Achievements: Social achievements of the integration plan include:

• Enhanced patient and healthcare worker satisfaction:

“The high-quality services provided in educational hospitals attract more people to these hospitals.” (Speaker 8)

• Acquisition of necessary workplace skills and familiarity with its challenges:

“Through integration, we were able to turn degrees into skills. Many non-medical universities only issue degrees. If someone wants to work, they must take additional courses to learn the necessary skills. We are pleased that all pharmacy, nursing, dentistry, and all other students are employed after graduation and are familiar with the work environment and its challenges.” (Speaker 9)

• Attraction of international students and the establishment of Al-Sibtain University in Iraq:

“We established the international branch of the Tehran University of Medical Sciences in Iraq under the name of Al-Sibtain University, and it was a great honor that our education progressed so much that neighboring countries requested it.” (Speaker 10)

• Increased life expectancy:

“Increased life expectancy in Iranian people, from under 50 years old before 1979 to over 75 years old after today.” (Speaker 7)

1.5 Economic Achievements: Economic achievements stemming from the integration plan encompass:

• Reduction of patient outflow expenses:

“Our younger generation may be unaware of the post-integration landscape. Previously, patients frequently sought treatment abroad, necessitating the involvement of the MoHME in facilitating foreign medical travel. Patients received foreign currency for treatment abroad.” (Speaker 2)

• Diminished costs associated with hosting foreign medical professionals:

“Foreign doctors often remitted their earnings to their home countries once a year, depleting valuable foreign exchange reserves. Also, the Iranian government provided their expenses, accommodation, and other living costs.” (Speaker 2)

2. Challenges and Barriers to Successful Integration Implementation

2.1 Strategic Level

• Absence of a well-defined roadmap:

“Integration has endowed us with significant capabilities, enabling evidence-based policy-making. This synergistic bond between researchers and policymakers, often elusive in other domains, is distinctly delineated within the integration framework and warrants increased attention.” (Speaker 3)

• Fragmented policy implementation:

“Currently, our actions predominantly exhibit organizational tendencies. We have yet to attain optimal operational efficiency, and the complete integration of the MoHME, encompassing healthcare networks, education, and research, remains an unfulfilled aspiration. Collaboration and unity between ministry departments, perhaps even the university deputy, are essential for directing efforts harmoniously.” (Speaker 11)

• Resistance to evidence-based policy:

“Evidence-based policy-making confronts significant challenges within our nation. Establishing widespread acceptance for such policies remains an unfortunate impediment, as policy-making procedures remain arbitrary. This underutilized potential within the integration system warrants intensified attention.” (Speaker 3)

2.2 Operational Level

• Limited access to accurate data:

“While respecting data confidentiality, our nation should not forfeit the ability to engage in evidence-based policy-making. Research must be accorded greater relevance in policy-making, embracing a holistic approach encompassing priority setting, documentation preparation, knowledge translation, implementation, and impact assessment.” (Speaker 3)

• Ritualistic practices:

“Our approach must eschew superficiality and ritualism. Drawing inspiration from authentic teachings, we should prioritize concepts such as health equity and human dignity.” (Speaker 3)

• Self-centeredness danger:

“While celebrating our achievements, it is crucial to acknowledge that complacency can impede progress. Vigilance is key to maintaining momentum.” (Speaker 3)

• Inadequate, sustainable resource allocation:

“The MoHME has perennially faced budgetary shortfalls and assorted obstacles, impairing its ability to fully harness the stable resources outlined in legislation. The budget allocation remains suboptimal.” (Speaker 12)

2.3 Influential Level

• Lack of awareness and justification among parliamentary representatives:

“Parliament representatives’ limited exposure to the MoHME’s operations contributes to abstraction in policy discussions. I invite officials, experts, and medical science professors to enlighten parliament representatives about the Ministry’s work.” (Speaker 12)

• Insufficient scientific resources and knowledge generation:

“Encouraging our professors to produce valuable scholarly work, rather than simply amassing articles, is vital. Many articles produced may lack practical utility, reflecting a disconnect between research and its application.” (Speaker 3)

3. Strategies for Enhancing Integration

3.1 Strategies for Improving Public Health

• Elevating public health initiatives:

“Prioritizing non-communicable diseases, such as cancer, stroke, heart diseases, diabetes, high blood pressure, and obesity, is paramount in advancing medical education integration into the healthcare system. Advances in healthcare have reduced the prevalence of communicable diseases, necessitating a stronger focus on non-communicable ailments by the MoHME.” (Speaker 11)

• Amplifying attention on rural healthcare services and health promoters:

“Sustaining the integration plan’s success mandates increased emphasis on rural healthcare services and the training of health promoters.” (Speaker 11)

3.2 Organizational Solutions

• Transition from structural integration to functional integration:

“While structural integration between education, research, and service delivery has made headway, further strides should be made towards functional integration. Educational institutions should take on greater responsibility for service provision.” (Speaker 8)

• Fostering interdisciplinary collaboration:

“Interdisciplinary discourse is imperative. The MoHME must collaborate with external entities in various fields for mutual benefit.” (Speaker 10)

• Attraction of elite talent:

“The MoHME should inspire and create an environment that fosters hope among students. Attracting and retaining elite individuals within the Ministry is crucial to harnessing their expertise to improve the nation’s healthcare system.” (Speaker 3)

3.3 Educational Solutions

• Keeping professors scientifically up-to-date based on societal needs:

“Expectations have evolved; professors should regularly update their knowledge to address societal needs. Static teaching methods must give way to dynamic, adaptable approaches.” (Speaker 10)

• Curriculum alignment with societal needs:

“Frequent curriculum revisions that align with societal requirements are essential. Outdated materials, which omit common domestic diseases, should be replaced with updated, context-specific content.” (Speaker 10)

3.4 Research Solutions

• Integration of medical, educational, and research projects:

“The integration plan should permeate projects, including the design of healthcare facilities. Infrastructure planning should embrace an all-encompassing, network-oriented approach incorporating education and research.” (Speaker 10)

• Engagement of research centers with society:

“Research centers’ value lies in their community engagement and responsiveness to societal needs. For example, dental schools should extend their services beyond their walls, addressing preventive and oral health within the community.” (Speaker 10)

• Research aligned with societal needs:

“Fundamental transformations demand research topics tailored to healthcare needs. Research initiatives must be responsive to society’s evolving requirements.” (Speaker 13)

Discussion

The 7^th National Conference on Scientific Authority, themed “Integration of Medical Education in the Healthcare System: Achievements and Manifestations of the Scientific Authority of the Islamic Republic of Iran,” marked a significant milestone in showcasing both a source of national pride and the scientific prowess of the Islamic Republic of Iran. Diverse professionals from the fields of medical education and healthcare convened at this conference to deliberate on and assess the challenges, opportunities, and strategies to bolster the integration of medical education within the healthcare system.

When delving into the subject of medical education integration, it is imperative to consider prior research efforts in this pivotal area. Curriculum studies have consistently emphasized the alignment of medical education curricula with the exigencies of the healthcare system. Learners must acquire practical experience within healthcare settings and possess the ability to apply their knowledge in real-world scenarios. This underscores the need for robust collaboration between medical educators and healthcare providers to ensure comprehensive and relevant medical education. For example, a study by Boulet and Van Zanten in
2014 emphasized the significance of credible medical school programs, specialized medical certifications, and licenses in upholding the quality of healthcare services (13). These processes should be meticulously designed to promote continuous professional development and lifelong learning.

In this context, the imperative is to harmonize medical education curricula with the healthcare system’s requirements, thus producing proficient healthcare professionals who can adeptly address the multifaceted challenges of healthcare delivery within their communities. Cooke and colleagues contend that revising medical education is paramount to equipping physicians with the competencies necessary to provide high-quality, patient-centered care in a rapidly evolving healthcare landscape (14).

Gonzalo and colleagues provide valuable insights into a systemic framework that underscores the pivotal role of integrating basic and clinical sciences into the education of 21st-century healthcare providers (15). This framework is considered indispensable in preparing healthcare professionals for effective engagement within a complex and dynamically evolving healthcare environment.

During the conference, Bagherifard introduced the concept of integration as the simultaneous fusion of education and empowerment (16). Zali construed integration as the intermingling of education, research, and services (17). Furthermore, Pezeshkian underscored the importance of establishing third, fourth, and fifth-generation universities, emphasizing the fusion of these three core elements and active engagement with society to gain a profound understanding of its future requirements (17). Hence, a university detached from society and lacking interaction cannot comprehensively and effectively serve the community. The integration of medical education and healthcare services has been shown to yield enhanced patient outcomes, offering holistic benefits in terms of healthcare delivery, patient satisfaction, and disease management. It also underscores the significance of interprofessional education in augmenting collaboration among diverse healthcare professionals.

Batalden and Davidoff posit that healthcare professionals should receive instruction in healthcare system enhancement, infectious disease prevention, and treatment, while fostering collaborative efforts to improve healthcare quality (18). Mohammadifard maintains that integration can elevate community health literacy in lifestyle modification, risk factor control, postponement of cardiovascular disease onset, disability reduction, and mortality delay (17).

From Vaziri’s perspective, integration is exemplified through community-based programs and the establishment of counseling, prevention, and treatment centers for infectious diseases, such as acquired immunodeficiency syndrome (AIDS), involving specialists from various medical disciplines (17). Einollahi contends that acquiring knowledge about innovative treatments, such as cell therapy, stem cells, regenerative medicine, and the production of knowledge-based products, can only be achieved through the integration of medical education and healthcare services (17).

Furthermore, Nasca et al. delve into the rationale and advantages of the Accreditation Council for Graduate Medical Education system for graduate medical education (19). Their research highlights that the next GME system seamlessly integrates medical education and healthcare by emphasizing outcomes and quality improvement (19). This underscores the role of the new system in ensuring that healthcare providers receive comprehensive training to deliver high-quality care, ultimately leading to improved patient outcomes.

According to Wartman and Combs, the transition of medical education from the Information Age to the Artificial Intelligence Age is imperative for facilitating the effective integration of medical education and healthcare systems (20). The incorporation of artificial intelligence holds the potential to augment patient care through personalized interventions and predictive analytics, ultimately leading to improved patient outcomes. Consequently, medical education should prioritize teaching skills related to harnessing artificial intelligence to advance patient care.

In this context, Nafar has highlighted several noteworthy achievements associated with integration, including technological advancements, novel pedagogical approaches, and the utilization of resources such as virtual healthcare facilities to enrich students’ learning experiences (17). Nevertheless, a thorough examination of the barriers' impeding integration is essential, encompassing fiscal constraints, deficient infrastructure, resistance to transformative change, and reluctance to embrace emerging technologies (21). Research indicates that innovative technologies, interprofessional education, and enhanced communication mechanisms can fortify integration. For instance, Bridges and colleagues have introduced three models for enhancing Interprofessional Education: The Collaborative Learning Model, the Clinical Education Model, and the Service-Learning Model (22). Their findings underscore the pivotal role of interprofessional education in preparing healthcare professionals for collaborative engagement within the intricate healthcare environment.

A systematic review by Reeves et al. revealed a clear association between interprofessional education and significant improvements in healthcare outcomes, particularly in patient safety, communication, and teamwork (23). Nonetheless, contemporary investigations suggest that the integration process has yet to reach its full potential or adapt to prevailing demands. Bagheri Lankarani attributes this to the absence of a coherent roadmap and a lack of comprehensive, policy-driven momentum (24). He aptly remarks,

“In Iran, we encounter substantial challenges in evidence-based policy-making, a lamentable situation since policy-making here often remains rooted in personal predilections. Integration endows us with indispensable capacities to be harnessed for formulating evidence-based policies. The symbiotic relationship between researchers and policymakers, frequently elusive elsewhere, is meticulously delineated within the integration framework, an oft-overlooked facet that merits heightened attention” (17).

Finally, the evaluation facet assumes paramount significance in ensuring the success of integration initiatives. A meaningful evaluation of the impact of integration on patient outcomes and the quality of care delivered is a pivotal determinant for future developments in this domain. It also highlights the importance of continual professional development and training for healthcare providers and educators to foster successful integration. A study conducted by on the consequences of integrating medical education into the healthcare system in Iran emphasizes that a comprehensive examination of the economic, social, developmental, and scientific ramifications of integration remains conspicuously absent (25). Current investigations predominantly rely on surveys and general assessments, with limited use of modeling and economic analyses.

Consequently, a precise assessment of the actual effects of integration remains elusive. In this context, Marandi conducted a study to assess the status of medical education integration within Iran’s public health framework (26). The findings revealed significant improvements in Iran’s healthcare landscape, particularly in remote and rural areas, attributed to integration efforts. Key achievements included the strengthening of healthcare networks, expanded access to potable water, better organization of health indicators, extension of vaccination programs, reductions in neonatal, maternal, and child mortality rates, increased population growth rates, and improvements in life expectancy (26, 27).

Ultimately, a comprehensive review of the literature highlighted a substantial research gap in evaluating the impact of integration on patient outcomes. Consequently, further investigations are crucial to assess the efficacy of various integration models, promote seamless coordination, and provide data-driven recommendations. This is essential to ensure effective collaboration between healthcare providers and educators.

Conclusion

The conference served as a platform for disseminating knowledge and facilitating professional networking among participants. Throughout the conference, significant emphasis was placed on the imperative of integrating medical education with healthcare systems within the realm of scholarly inquiry. This integration necessitates a concerted effort involving collaboration between healthcare providers and educators to enhance the quality of medical education and improve clinical performance. Moreover, during the conference, the challenges and opportunities inherent in merging medical education with healthcare systems were carefully considered. This comprehensive examination addressed a range of issues, including financial considerations, strategic planning, communicative intricacies, and cooperative initiatives among diverse stakeholders. A thorough analysis of these challenges is paramount, underscoring their importance in guiding further research endeavors. Such investigations are essential to ensure the long-term sustainability and efficacy of integrating medical education and healthcare services.