Designing and implementing a unique model of horizontally and vertically integrated teaching methodology for the students of pre-clinical years

Designing and implementing a unique model of horizontally and vertically integrated teaching methodology for the students of pre-clinical years | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Designing and implementing a unique model of horizontally and vertically integrated teaching methodology for the students of pre-clinical years Nazish Rafique, Ahmed AAlSunni, Ayad Mohammed Salem, Rabia Latif, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9426343/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Medical education is shifting from traditional subject-based models to integrated approaches. But, many institutions struggle with implementation due to a lack of proper guidelines eventually returning to the traditional curriculum.We tried to fill these gaps by designing and implementing a unique model of Horizontally and Vertically Integrated Teaching System (HAVIS)that aimed to: Document a stepwise guide for HAVIS implementation &Develop multidisciplinary teaching materials and integrated examination tools.This observational study involved 50 faculty members and 247 third-year medical students at IAU during 2023–2024 academic year. Ten modular committees, comprising experts from all basic science departments, were formed. The implementation followed a structured "Stepwise Guide". Each modular team formulated a study guide that featured 10–12 clinical scenarios with horizontally and vertically integrated discipline-specific "extended stems". Each module ended with an exam including 30–40% of horizontally and vertically integrated questions. In a cohort comparison, students exposed to HAVIS showed a statistically significant increase in the “A" grades (from 11% to 22%) and decrease in failure (F) rates (from 21.65% to 13.5%) (p < 0.05). In addition, 85% of students and 95% of faculty members believed that HAVIS is better than traditional teaching system and should be continued in future. Therefore, we conclude that HAVIS is an effective teaching methodology that stimulates deep and meaningful learning. Moreover, we have designed a “Stepwise integrated curriculum guide” and “Horizontally and vertically integrated modular Study guides” which can serve as valuable tools for case-based teaching in pre-clinical years at National and International level. Horizontal Integration Vertical integration Horizontally and vertically integrated teaching system (HAVIS). Introduction There is a worldwide trend of change in Medical Education from a subject-based to a system-based approach. Several studies from various medical universities all over the world indicate that a system-based Horizontal and vertically integrated curriculum may be considered one of the major reforms that will prepare better future physicians (Quintero GA et al., 2016 ). Vertical integration (VI) is the integration between the curriculum's clinical and basic science sections. In preclinical years, VI is usually achieved by introducing case scenarios or vignettes in the lectures and other teaching activities. (Wijnen et al.,2020) The early exposure of students to clinical scenarios provides them with immediate opportunities to apply basic scientific knowledge relevant to the real world with long-term retention and analytic clinical reasoning practiced in problem-solving. (Norman et al., 2009) It can occur throughout the curriculum with the basic medical and clinical sciences beginning together in the early years of the curriculum and continuing until the later years. More emphasis may be placed on the basic medical sciences in the earlier years and on clinical sciences and the practice of medicine in the later years. (Rafique, 2014) Horizontal integration (HI) blends the related basic science disciplines (anatomy, physiology, biochemistry, microbiology, pharmacology, and Pathology). This form of integration is often accomplished by the elimination of departmentally oriented teaching (Adam, 2015). Introducing an integrated curriculum may be considered as one of the major reforms to prepare better physicians for the next century (Jone et al., 2001). Benefits of Horizontally and Vertically Integrated Teaching System (HAVIS) for the students may include improved motivation; enhanced deep learning; Linking the theory of basic science subjects to clinical practice (Knowledge application); Integrating the knowledge of various basic science subjects; Preparation for clinical practice; smooth transition from basic to clinical years; Becoming Better Future Physicians and Enhanced problem-solving and critical thinking. (Brynhildsen et al.,2002; Malik et al., 2011; Ramnarayan et al., 2010; Dolmans et al., 1997 ). The benefits for the faculty members may include Identification of Curriculum overlapping; Prevention of Curricular hypertrophy and curricular overload; curricular reforms; Logical sequencing of the timetable; Faculty development and Enhanced collaboration between various departments (Kalpana et al.,2011; Tresolini et al., 1994; Blue et al., 2000 ; Harden et al., 2000) Although HAVIS is being practiced in many International Medical universities, various reports have identified that Medical Educationists from all over the world are facing major challenges which leads to the failure of HAVIS, eventually returning to the traditional curriculum (Basukala et al., 2021).The reasons for the failure of HAVIS include: The lack of proper guidelines to formulate and implement the “HAVIS” curriculum; Lack of Integrated examinations for the students of preclinical years. (Some universities claim to deliver an integrated curriculum, but their examination systems are disintegrated); Lack of valid resources and authentic reading materials for HAVIS for both the teachers and students (Tamimi et al., 2018 ; Daly et al., 2024 ) We tried to fill the above-mentioned gaps by designing and implementing a unique model of HAVIS at the College of Medicine IAU, which will not only provide the step wise guidance to formulate the HAVIS curriculum but also aimed in designing and provision of authentic reading materials for HAVIS. Our study focused on three main objectives: To collect and analyze the data including students’ results, and students' and faculty' feedback questionnaires about HAVIS. This can provide us with identification that either HAVIS is better than the traditional curriculum. To stepwise document the process of designing and implementation of HAVIS. This “stepwise guide” can be beneficial to medical educators all over the world. To design “Horizontally and vertically integrated Lectures, Tutorials, Exam questions & Study guides” for the faculty members and the students of the pre-clinical years. Materials &Methods This observational study was conducted at the College of Medicine IAU. A total of 247 Students of MED-301 including 130 Female + 117 Male students were exposed to the unique HAVIS system in the year 2023–2024. Ethical approval was taken form the deanship of scientific research, IAU (IRB Approval # 2024-01-685) The following steps were taken for the formulation and the delivery of HAVIS at IAU College of Medicine. The proposed plan of the horizontally and vertically integrated teaching system (HAVIS) was approved by the chairperson and 2nd year 3rd year management committee of the College of Medicine IAU in March 2022. The first step was the formation of committees for various Modules that can work together to achieve this target. Formation of 10 Modular committees For an effective and efficient delivery of HAVIS, 10 Modular committees were formed. Each modular Committee was headed by an “expert and experienced faculty member” and included 10–12 team members from all the basic science departments (Anatomy, Physiology, Biochemistry, Microbiology, Pharmacology, and Pathology). To orient the faculties with the idea of HAVIS a series of training sessions and workshops were conducted. The committees started working in April 2023. The main purpose of each committee was to deliver their module in a horizontally and vertically integrated manner. Each committee formulated the following documents before the start of their module. • Case-based study guide • Multidisciplinary HAVIS PowerPoint • Multidisciplinary HAVIS Tutorial • HAVIS questions for the exam • HAVIS timetable These documents were finalized after several meetings and discussions among the team members. Following is the “Stepwise documentation for the formulation and implementation of HAVIS at IAU” A Case-based study guide The formulation of a case-based study guide was the first step towards HAVIS system. This guide included 10–12 common case scenarios related to the specific module. The cases were written by the committee members and were later sent to a clinician for final approval. Later on, every department member added an extended stem with relevance to their subject to each Case. The final study guide with Cases and extended stems was shared with the whole team. The leader ensured that the required cases and the related objectives were being used by all the department members in their lectures and other teaching activities. These cases and extended stems were also used in the formulation of Multidisciplinary HAVIS sessions, HAVIS tutorials, and integrated questions. In fact, these study guides served as a “Primary document” for all the teaching activities related to HAVIS. This study guide also included detailed information of the objectives from all departments to be delivered during the module. Moreover, the mode of delivery and learning strategies for each objective were also identified i.e. lectures, tutorials, labs, and PBL sessions Multidisciplinary HAVIS PowerPoint presentation with input from all departments The group leader coordinated with the team members and formulated a HAVIS PowerPoint presentation including the 8–10 most common case scenarios related to their module (Vertical integration). Each case scenario was followed by interactive slides and integrated questions from various departments (Horizontal integration). So, the case scenarios that were already vertically integrated in the lectures of various subjects were now horizontally integrated in the Multidisciplinary HAVIS ppt. At the end of each module, one whole day was designated as a “HAVIS DAY”. Multidisciplinary HAVIS session” was delivered in the first 3 hours of HAVIS Day. Multidisciplinary HAVIS Tutorial The HAVIS tutorial was also designed by close collaboration between various department members of the modular team. It included 4–6 case scenarios (that were not covered in the multidisciplinary HAVIS ppt). Each case scenario was followed by high-order C2&C3 questions from various departments (Horizontal integration). This tutorial also included information about the reference reading material. The integrated tutorial included multiple assessment methodologies that stimulate critical thinking in the students. e.g. the use of diagrams, fill-in-the-blanks, matching questions, short answer questions, etc. Horizontally and vertically integrated questions An exam was held at the end of each module. Group leader of each module was responsible for the formulation of the blueprint for the exam. 30% of the total questions in the exam were integrated. A separate portion in each exam paper was assigned for integrated questions. Each Integrated question started with a case scenario (vertical integration), followed by 4–5 high order thinking questions from various departments (horizontal integration). With the help of our modular teams, we were able to formulate more than 300 high quality Integrated questions, which are being successfully utilized in the modular exams at IAU. (All these questions have passed through multiple quality checks; low quality questions were removed from the question banks). (See the sample of an integrated Question in appendix # 1.) Horizontally and vertically integrated timetable The Modular leader was responsible for the formulation of an integrated timetable for their module. The timetable was arranged in a logical sequence, starting with the lectures of Anatomy followed by Physiology, Biochemistry, Microbiology, Pathology and Pharmacology. The PBLs and clinical skills sessions were interwoven at their best possible place to facilitate and enhance vertical and horizontal integration and deep learning. This practice solved many problems related to the sequential organization of the timetable. Modus operandi of Delivering HAVIS A clinical scenario was introduced as a trigger at the beginning of the specific theme, and the objectives revolving around that scenario were covered in the next 2 to 3 days. Usually, two case scenarios were covered each week. Almost every lecture on a specific theme started with the same case scenario. However, every department was allowed to make minor modifications in the case, as per their learning objectives. For example, in the case of Gastric ulcer disease, we introduced the case of “34-year-old lady Fatma with the symptoms of Gastric ulcer”. The Physiology department used this case as a trigger to cover the objective of “Physiological functions of stomach” The Microbiology department added an extended stem about the “laboratory test to diagnose H-Pylori”, the Pharmacology department added an extended stem about the “management of H-Pylori”, Anatomy department added the extended stem about the perforation of the gastric ulcer in order to teach the Anatomy of stomach and related structures. (These cases and triggers were taken from the “Case based study guides” formulated by the modular teams before the beginning of each module). So, the students of MED-301 were familiarized with the same patient Fatma in their lectures of Physiology, Anatomy, Biochemistry, Microbiology and Pharmacology (vertical integration). Finally, “Fatma’s Case of Gastric ulcer disease” was presented in the “Multidisciplinary HAVIS session” where students were given an opportunity to connect related topics across different disciplines, resulting in concurrent learning in Anatomy (structure of the stomach), Physiology (functions of stomach), Microbiology (Diagnostic tests for H-Pylori) and Pharmacology (Management of H-pylori). This approach helped the students to see the interconnectedness of different disciplines and how they contribute to understanding the human body in health and disease. Special care was taken to keep a balance between clinical and basic science knowledge. As the purpose of Vertical integration in preclinical years is just to orient the students with the common clinical conditions, and to help them understand the practical application of basic science knowledge. Therefore, a ratio of 30–70 was taken into consideration, 30% of knowledge should be clinical and 70% should be related to the basic science subjects. Simple cases were formulated where the objectives revolved mostly around the normal structure and functions. (See the sample of “Fatmas’ case of gastric ulcer disease, delivered by HAVIS” attached in appendix # 2.) Data Analysis Statistical analysis was performed by SPSS Version 20. The students and faculty feedback responses were calculated by using Five -point Likert-Type scale. The percentages were analyzed for all the questions. The comparison of exam results between the HAVIS and the traditional groups was done by Chi-Square Test. P value less than 0.05 was considered as statistically significant. Open-ended comments of the students and faculty members were qualitatively analyzed, which helped us to identify various strengths and weaknesses of the system. Results Examination and Results An exam was held at the end of each module. We performed a comparative analysis of average examination results between HAVIS and non-HAVIS students. (The Average Exam Grades refer to the Cumulative exam grades of Midterm l+ Midterm2 + End of term exam). Table 1 shows the comparison of the exam results of the same group of students when exposed to two different teaching systems, i.e. HAVIS vs Non HAVIS, indicating that HAVIS leads to a statistically significant increase in A and decrease in F grades of the students. Table 2 shows the comparison of exam results between two different groups of students who were exposed to two different teaching systems, i.e. HAVIS vs Non HAVIS. This comparison also showed that the group exposed to HAVIS had a statistically significant increase in B and decrease in the F grades of the students. These comparisons indicate that the students exposed to HAVIS system showed a significant decrease in the failure rate in the exams, thereby indicating that HAVIS system may be superior to the traditional curriculum for the students of pre-clinical years. Student and faculty feedback At the end of the year, the students and the faculty members involved in HAVIS filled an online questionnaire. Analysis of the feedback questionnaires helped us to understand the benefits of HAVIS. Moreover, the comments from students and faculty members also provided insights to improve in future. Students’ feedback questionnaire (including 12 questions) was shared with 247 students of MED-201 at IAU. The response rate was 85% as the questionnaire was filled out and returned by 210 students. Responses of the students to the HAVIS questionnaire are summarized in Table 3 . Faculty feedback questionnaire (including 12 questions) was shared with 40 faculty members who were involved in the designing and implementation of HAVIS at IAU. The response rate was 87.5% as 35 out of 40 faculty members filled and returned the questionnaire. Responses of the faculties to the HAVIS questionnaire are summarized in Table 4 . Based on the improved exam results and positive feedback from students and faculty members, it was decided by the 2nd year and 3rd year management committee to continue this teaching methodology in future for the students of pre-clinical years at IAU. We also received valuable open comments from the students and the faculty members, which helped us improve in future. Open comments from faculty members The modular leaders should meet frequently to share their experiences with each other. The training workshops should be frequent. Formulation of horizontally and vertically integrated questions is a difficult task; it needs further training of the staff. Open comments from students The students’ participation in the HAVIS sessions should be increased. The students participating in the HAVIS sessions should be provided “Appreciation certificates”. The teaching sessions should include online quiz focusing on various aspects of integration. The use of simulated patients can make vertical integration even more interesting and meaningful. There should be practice sessions for integrated questions. Some case scenarios were long and complicated, the cases should be simple and more emphasis should be on basic rather than clinical concepts. Table I. Comparison of Average Exam Results of Class of Med-2022 (With and without Horizontal and vertical integration) Average exam grades of MED-2022 (Without HAVIS) 2nd Year exam results Average exam grades of MED-2022 (With HAVIS) 3rd Year exam results P Value Grade A = 11% Grade A:22% 0.02* Grade B = 29% Grade B = 31% 0.09 Grade F: 21.65% F: 13% 0.04* This table shows the comparison of exam results of the same group of students when exposed to two different teaching systems, i.e. HAVIS vs Non HAVIS. Average Exam Grades= Cumulative exam grades of Midterm l+ Midterm2 + End of term exam. HAVIS: Horizontally and vertically Integrated teaching system *P value less than 0.05% was considered statistically significant. Table II. Comparison of average exam results between the Class of MED- 2021(without HAVIS) and MED- 2022(with HAVIS) Average exam grades of class of MED-2021 (Without HAVI S) 3rd year exam results Average exam grades of class of MED-2022 (With HAVI S) 3rd year exam results P value Grade A = 19% Grade A:22% 0.08 Grade B = 16% Grade B = 31% 0.04* F = 17% F: 13% 0.06 This table shows the comparison of exam results between two different groups of students who were exposed to two different teaching systems, i.e. HAVIS vs Non HAVIS. Average Exam Grades= Cumulative exam grades of Midterm l+ Midterm2 + End of term exam. HAVIS: Horizontally and vertically Integrated teaching system *P value less than 0.05% was considered statistically significant. Table III : Students feedback on "Horizontally and vertically integrated teaching system” at IAU (N = 210 students) Questions Agree & Strongly Agree Disagree & Strongly disagree Uncertain Do you think that HAVIS is better than traditional teaching system? 85% 2% 13% After the implementation of HAVIS, have you noticed an improvement in the sequence of the lectures in the timetable? 90% 1% 9% Does vertical integration (adding cases in lectures) help you in better understanding of concepts? 88% 5% 7% Does horizontal integration (integration between various departments) help you to integrate knowledge of different basic science subjects? 86% 3% 11% Does HAVIS help you to link the theory to clinical practice? 91% 4% 5% Does HAVIS provoke your critical thinking? 83% 5% 12% Does HAVIS promote deep and meaningful learning? 84% 7% 9% Do you think that the clinical knowledge gained during HAVIS would be helpful to you in future clinical years? 92% 2% 6% Do you think that HAVIS can help you to become better physicians? 78% 10% 18% Do you think that the integrated questions provoked your critical thinking? 81% 6% 13% Do you find the “Horizontally and vertically integrated sessions” at the end of each module, interesting? 77% 12% 11% Do you think that HAVIS should continue in future? 90% 4% 6% HAVIS Horizontally and vertically Integrated teaching system The values in the table are the responses of Students in percentages Table IV : Faculty feedback on "Horizontally and vertically integrated teaching system” at IAU (N = 40) Question Agree & Strongly Agree Disagree & Strongly disagree Uncertain Is HAVIS better than traditional teaching system? 95% 3% 2% Does HAVIS helped in the better sequencing of the lectures and improvements in the timetable (e.g. delivery of Microbiology and Pharmacology lectures after the delivery of Anatomy and physiology lectures)? 92% 3% 5% Does vertical integration (adding cases in lectures) help the students in better understanding of concepts? 85% 8% 7% Does horizontal integration (integration between various departments) help the students to integrate knowledge of different subjects? 91% 4% 5% Does horizontal integration (integration between various departments) improve the interaction and coordination between various departments? 82% 10% 8% Does HAVIS help the students to link the theory to clinical practice? 93% 3% 4% Does HAVIS provoke critical thinking in the students? 88% 7% 5% Does HAVIS promote deep and meaningful learning for the students? 80% 10% 10% Do you think that the clinical knowledge gained during HAVIS would be helpful to the students in their future clinical years? 91% 6% 3% Do you think that HAVIS can help our students to become better physicians? 87% 3% 10% Do you feel that students’ participation in your lectures have improved by introducing vertical integration? 75% 16% 9% Do you think that student’s assessment by vertically and horizontally integrated questions stimulates high order thinking? 78% 14% 8% Do you think that HAVIS helped you in your personal growth as a teacher? 89% 6% 5% Do you think that HAVIS should continue in future? 93% 4% 3% HAVIS Horizontally and vertically Integrated teaching system The values in the table are the responses of faculty members in percentages. Discussion The implementation of the HAVIS has created a transformative impact on the students and faculty members at IAU. Our results demonstrate that HAVIS system has significantly enhanced the academic performance of the students. Moreover, this system has also received overwhelming support and positive feedback from both students and faculty members of IAU. The core finding of our study was that after the implementation of HAVIS, there was a statistically significant increase in grades (A and B) and a notable decrease in failure percentage (F grades). Our findings are in line with the study conducted by Brauer and Ferguson, which highlights that an integrated teaching approach helps the students to relate their knowledge effectively, resulting in the long-term retention of knowledge and improved performance in exams (Allouch et al., 2024 ) Moreover, the study results of Al-Qahtani et al. indicated that the students exposed to an integrated curriculum showed high exam scores and low failure rates as compared to the students of a traditional curriculum (Brauer et al., 2015). These findings are in accordance with our study results where we found a statistically significant decrease in the failure rates of the students after the implementation of HAVIS. These findings indicate that when students are provided with an opportunity to link anatomy, Physiology, Biochemistry, Microbiology and Pharmacology (horizontal integration) with clinical cases (vertical Integration), there is a shift from rote memorization to critical thinking and knowledge application which results in improved cognition and better exam performance. In addition, it has been observed that the medical students exposed to HAVIS systems show a higher passing rate in National and international post-graduation exams. As the horizontal and vertical integration promotes deep understanding and meaningful learning, thereby forming stronger cognitive connections and enhancing the abilities to retain information for a longer period of time (Dahle et al., 2002 ). Feedback reports from our students indicated that HAVIS is better than traditional teaching system. These findings were similar to the study results of Khalil et al. where 82% of their student’s favored integration over traditional curriculum, that is very close to our reported student satisfaction rate (85%) (McLean et al., 2016). In addition, our faculty's positive response (95% favoring HAVIS) is also consistent with international literature. A review article by Muller et al. has pinned down that although integrated curriculum requires more planning and greater collaborative efforts, its benefits are much higher than a traditional curriculum (Khalil et al., 2017 ). Our study findings have revealed that although the designing and implementation of HAVIS system is challenging and demanding compared to the traditional system, but it provides multiple long-term benefits to the students and the faculty members. One of the major advantages of HAVIS system is that it helps to Link the theory of basic science subjects to clinical practice (Knowledge application). (Agreed by 93% faculty and 91% of students at IAU). The early exposure of students to clinical scenarios provides them with immediate opportunities to apply basic sciences knowledge relevant to real world patients. Our results mirror the findings of Dahle et al. who reported that students in a vertically integrated curriculum are better prepared for clinical rotations (Brauer et al., 2014). HAVIS system provides an early exposure of the students to the case scenarios and vignettes which allows them to connect what they learned to patient diagnosis and management. This clinical application of Basic science knowledge not only helps in a smooth transition from basic to clinical years but also prepares the students for the future clinical practice resulting in producing better future Physicians. (These findings were supported by 91% faculty and 92% of students at IAU). As the HAVIS system was designed for pre-clinical years, therefore the challenge faced by our faculty members was to formulate simple and relevant case scenarios that could be used as the triggers in the lectures with more emphasis on basic rather than clinical teaching. Despite tremendous efforts by the modular teams, we still received comments from the students indicating that some of the vignettes were complex and irrelevant and the facilitators spent more time in explaining the clinical rather than the basic science concepts. The study of Rafique &Hardey et al. also highlights this challenge and emphasizes keeping a balance between basic and clinical knowledge. They proposed a 30:70 ratio of clinical/basic science knowledge, and recommended keeping the case scenarios simple and understandable for the students of pre-clinical years (Muller et al., 2008 ; Rafique et al., 2014). Our students also suggested to use simulated patients and making use of Artificial intelligence (AI), to make vertical integration "more meaningful” and “interesting”. Some faculties did use simulated patients, but this practice was limited. Therefore, it is recommended to arrange frequent AI training programs and workshops for the faculty members, which can help them to save hundreds of hours in manual drafting of cases while maintaining high educational standards. Another major benefit of HAVIS system is that it serves as a diagnostic tool for the curriculum itself and helps to identify overlaps, repetitions, and gaps. Held et al. demonstrated that an integrated curriculum not only helps in the logical sequencing of the timetable (Ensuring that Physiology precedes Microbiology and Pharmacology) but also identifies the redundant information across departments which aids in preventing curricular hypertrophy and curricular overload(Hardy et al., 2011). Harden ( 2000 ), the pioneer of the "Integration Ladder," also spotlighted that integration in medical curriculum is essential to prevent the "information explosion" which ultimately ensures that only the most relevant, "must-know" content is prioritized (Held et al., 2023 ). Our study results have also elaborated the similar findings. The faculty members at IAU have reported that implementation of the HAVIS system helped them to: Identify repetition and overlapping of topics between various subjects; Recognize some important missing topics in the curriculum and formulate a logically sequenced timetable. These changes were highly appreciated by the students and teachers at IAU. (90% Students and 92% Teachers noticed an improvement in the curricular delivery and timetable sequence after the implementation of HAVIS). One of the main strengths as well as the biggest challenge of our HAVIS system was the formulation of horizontally and vertically integrated assessments (HAVIA). HAVIA is considered as a "gold standard" for assessment in modern medical education, yet it remains one of the most difficult transitions for faculty to make. While many institutions claim to have adopted an 'integrated' curriculum, a discrepancy often exists between delivery and assessment. Many such programs remain 'integrated in name only,' where lectures are grouped by organ system, but examinations remain dis-integrated and segregated into departmental blocks. And this is considered as one of the biggest reasons for failure of HAVIS (where integrated curriculums eventually revert to traditional teaching patterns because the assessment methods never truly changed) (Harden et al., 2000). Keeping these facts in mind, we placed special efforts to design “Integrated assessments” for each module. A complete section was dedicated to integrated questions in each Modular exam (Containing 30–40% of integrated questions). However, this transition was not without hurdles; the primary challenges identified include the logistical difficulty of inter-departmental coordination, faculty training and the significant time investment required to draft high-quality, validated integrated items (Gleason et al., 2013 ) It has been found that "curriculum drift" occurs when faculty members are not well trained in writing multi-step vignettes and they may revert to what they know: testing isolated facts within their own specialty (Kulasegaram et al., 2019). In order to avoid this problem, we conducted several training workshops for the Modular leaders and the faculty members of each team. The knowledge and skills gained during these training sessions were beautifully implemented by our faculty members in their modules and 89% of the teaching staff reported that HAVIS helped you in their personal growth as a teacher. Another strength of our study is that we have formulated” Horizontally and vertically Integrated study guides” for the medical educators and the students of preclinical years. (Kindly refer to the methodology section for the details). Because various reports have indicated that a major challenge faced by the medical students and the medical educators all over the world is the unavailability of authentic reading material for an integrated curriculum. In the current HAVIS practice, the students just have to rely upon the notes or PowerPoint presentations formulated by the faculty members (Schmidt et al., 2007; Atta et al., 2020 ). We have tried to fill this major gap by providing “Horizontally and vertically integrated case-based study guides” which can be a breakthrough and a valuable tool for case-based teaching in basic medical sciences at a global level. Based on our study results we can summarize that HAVIS system promotes deep learning; increases student motivation by showing clinical relevance; improves exam performance; helps in faculty development; streamlines the curriculum; helps in the smooth transition from basic to clinical years and produces the physicians who are not just knowledgeable, but clinically ready. But at the same time HAVIS is associated with various challenges including high faculty workload; faculty resistance; intense inter-departmental collaboration; difficulty in standardizing difficulty levels across disciplines; potential for "fragmented" and non-integrated assessments. These problems can be solved by the formulation of dedicated “Modular committees” for each body system. Each committee should be headed by “subject champions” from the basic and clinical science. Each committee should act as a quality control hub for the formulation and delivery of the content related to their module in a perfect way. In addition, multiple workshops should be conducted to train the faculty members on various aspects of integration and frequent meetings of the committee members should be held to ensure the horizontal links between subjects. Moreover, we also recommend using of “Stepwise guide for designing the HAVIS curriculum”, “HAVIS study guides” and “Digital item banks” to reduce the long term workload without compromising high quality standards. Conclusion HAVIS is an innovative and effective teaching methodology that stimulates deep and meaningful learning resulting in improvement in exam results. Moreover, we have documented the process of designing and implementation of HAVIS at IAU in a stepwise manner in the methodology section. This “stepwise guide” can be beneficial to medical educators all over the world. In addition, we have formulated “Horizontally and vertically integrated Study guides” for the faculty members and the students of the pre-clinical years. These documents can be a valuable tool for case-based teaching in basic medical sciences at National and International level. Declarations Funding No funding was received for conducting this study Statement of declaration No conflicts of interest are declared by the authors. Data transparency Statement All authors declare that all data and materials comply with field standards. Ethical approval Ethical approval was taken form the deanship of scientific research, IAU (IRB Approval # 2024-01-685). Consent to participate Informed consent was obtained from all individual participants included in the study. Authors contribution Prof. Nazish Rafique & Prof Ahmed AAlSunni have contributed to the Conception/design of the research, Collection of data and writing the manuscript. Dr. Ayad Salem, Prof. Rabia Latif and Dr. Khalood AlKhater helped in data collection and drafting the methodology and discussion section. Drs. Reem Aldossary, Yousaf Begum and Lubna Ibrahim AlAsoom helped in the data collection, data analysis and writing the results section. All the authors have read the final manuscript and gave the final approval. All the authors also Agree to be held accountable for the work. References Adam C, Diehl L, Reader L, Hamosh A, Bodurtha JN (2015) Horizontal integration of OMIM across the medical school preclinical curriculum for early reinforcement of clinical genetics principles. Genet Sci 17(2):158–163 Allouch S, Ali RM, Al-Wattary N et al (2024) Tools for measuring curriculum integration in health professions’ education: A systematic review. BMC Med Educ 24(1):635 Atta IS, El-Hag MA, Shafek IS, Al-Ghamdi HS, Al-Ghamdi TH (2020) Drawbacks in the implementation of an integrated medical curriculum at medical schools and their potential solutions. Educ Med J 12(1):29–34 Basukala A, Chaudhary K (2021) Early clinical exposure in preclinical years of medical school. 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Int J Educational Res Open 7(5):100366 Dolmans DH, Snellen-Balendong H, Wolfhagen CP (1997) Seven principles of effective case design for a problem-based curriculum. Med Teach 19(3):185–189 Gleason BL, Siracuse MV, Canedo AR, Sullivan DL, Galt KA, Mehanna AS, Shcherbakova N, Lin AY (2013) An integrated case studies course to help students apply health outcomes and pharmacy management concepts. Am J Pharm Educ 77(8):170 Harden RM (2000) The integration ladder: A tool for curriculum planning and evaluation. Med Educ 34(7):551–557 Hardy KJ, Snaith ML (2011) How much is enough? Basic science in the curriculum. J R Soc Med 104(1):12–14 Held N, Jimenez S, Lockspeiser T, Adams JE (2023) Designing a shortened preclinical basic science curriculum: Expert-derived recommendations. Acad Med 98(8):922–928 Jones R, Higgs C, de Angelis C, Prideaux D (2001) Changing face of medical curricula. Lancet 357(9257):699–703 Kalpana K, Vijaya R, Seema S (2011) Students' perception in teaching in an integrated undergraduate medical curriculum. J Clin Diagn Res 5(6):1258–1259 Khalil MS, Al-Eidi S, Al-Sairafi Z, Al-Khashan H (2017) Students' perceptions of an integrated medical curriculum in a Saudi medical school. J Fam Commun Med 24(1):45–51 Kulasegaram K, Bhola S, Casimiro L, Bryden P (2013) Cognitively integrated basic science in medical education: Links to contemporary theory and practice. Acad Med 88(10):1576–1585 Malik AS, Malik RH (2011) Twelve tips for developing an integrated curriculum. Med Teach 33(2):99–104 McLean SF (2016) Case-based learning and its application in medical and health-care fields: A review of worldwide literature. J Med Educ Curric Dev, 3 , JMECD.S203772. Muller JH, Jain S, Loeser H, Irby DM (2008) Faculty development for an integrated medical curriculum. Med Educ 42(5):445–455 Norman G (2009) Teaching basic science to optimize transfer. Med Teach 31(9):807–811 Quintero GA, Vergel J, Arredondo M, Ariza MC (2016) Integrated medical curriculum: Advantages and disadvantages. J Med Educ Curric Dev 3:35–39 Rafique N (2014a) Designing and implementation of vertically and horizontally integrated endocrinology and reproduction module. Pakistan J Physiol 10(3–4):12–16 Rafique N (2014b) Importance of vertical integration in teaching and assessment of physiological concepts. J Taibah Univ Med Sci 9(4):282–288 Ramnarayan K, Hande S (2010) Thoughts on self-directed learning in medical schools: Making students more responsible. Johns Hopkins University Schmidt HG, Rikers RM (2007) How expertise develops in medicine: Knowledge encapsulation and illness script formation. Med Educ 41(12):1133–1139 Tamimi HE, Nurhussen A, Rohra D, Ouban A, Alshadoukhy A, Alkattan W, Kemahlı S (2018) Vertical integration in clinical years of medical education. Educ Med J (TED) 17(52):27–34 Tresolini DA, Shugars DA (1994) An integrated health care model in medical education: Interviews with faculty and administrators. Acad Med 69(3):231–236 Wijnen-Meijer M, van den Broek S, Koens F, ten Cate O (2020) Vertical integration in medical education: The broader perspective. BMC Med Educ 20(1):20–24 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9426343","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":623601214,"identity":"7eca49e9-f172-4083-8407-0e0c28df2735","order_by":0,"name":"Nazish Rafique","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYJACZiBm7GeGs4nVMrOZZC0bDhCrxVz6jOHnwhwb2c3HmZ9JMFRYJzbwH36AV4tlX46x9MxtacbbDrOZSTCcSU9skEgzwKvF4AyPgTTvtsOJ2w4zmEkwth0GamEgqMX4N++2/4mbm9m/STD+A2rhP/6BkBYzoC0HEjcw8wBtaQBqYcghZAtbmTXvtmTjGYd5ii0SjqUbt0nkFBDQwrz5Nu82O9n+/uMbb3yosZbt5z++Aa8WBgYOJGckADEbAfVAwP6AsJpRMApGwSgY2QAAn1tCwB6rJCQAAAAASUVORK5CYII=","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":true,"prefix":"","firstName":"Nazish","middleName":"","lastName":"Rafique","suffix":""},{"id":623601215,"identity":"8f1ab613-e505-4269-b487-fc81ca51899b","order_by":1,"name":"Ahmed AAlSunni","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"AAlSunni","suffix":""},{"id":623601216,"identity":"edea351e-1e24-4d36-9872-8db2d7d767a5","order_by":2,"name":"Ayad Mohammed Salem","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Ayad","middleName":"Mohammed","lastName":"Salem","suffix":""},{"id":623601217,"identity":"1bfe4bfe-41d2-4a30-bed3-5827c5271c05","order_by":3,"name":"Rabia Latif","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Rabia","middleName":"","lastName":"Latif","suffix":""},{"id":623601218,"identity":"d4c42b34-4a0d-4247-9eed-e2f576308a31","order_by":4,"name":"Khulood Mohammed AlKhater","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Khulood","middleName":"Mohammed","lastName":"AlKhater","suffix":""},{"id":623601219,"identity":"bf8bf387-f4bf-4d97-920b-94c462d5a45d","order_by":5,"name":"Reem Aldossary","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Reem","middleName":"","lastName":"Aldossary","suffix":""},{"id":623601220,"identity":"10c3e607-5f92-498e-83b6-911b7701f9d6","order_by":6,"name":"Yousaf Begum","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Yousaf","middleName":"","lastName":"Begum","suffix":""},{"id":623601221,"identity":"f86d4f15-f0fb-4987-bd03-6451294ef855","order_by":7,"name":"Lubna Ibrahim AlAsoom","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Lubna","middleName":"Ibrahim","lastName":"AlAsoom","suffix":""}],"badges":[],"createdAt":"2026-04-15 11:37:00","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9426343/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9426343/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107039059,"identity":"09aac56e-6699-448a-9a23-e642ac5e4a89","added_by":"auto","created_at":"2026-04-16 05:26:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1069536,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9426343/v1/eaaed2fa-4ee1-4736-a022-233db56079fe.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eDesigning and implementing a unique model of horizontally and vertically integrated teaching methodology for the students of pre-clinical years\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere is a worldwide trend of change in Medical Education from a subject-based to a system-based approach. Several studies from various medical universities all over the world indicate that a system-based Horizontal and vertically integrated curriculum may be considered one of the major reforms that will prepare better future physicians (Quintero GA et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVertical integration (VI) is the integration between the curriculum's clinical and basic science sections. In preclinical years, VI is usually achieved by introducing case scenarios or vignettes in the lectures and other teaching activities. (Wijnen et al.,2020) The early exposure of students to clinical scenarios provides them with immediate opportunities to apply basic scientific knowledge relevant to the real world with long-term retention and analytic clinical reasoning practiced in problem-solving. (Norman et al., 2009) It can occur throughout the curriculum with the basic medical and clinical sciences beginning together in the early years of the curriculum and continuing until the later years. More emphasis may be placed on the basic medical sciences in the earlier years and on clinical sciences and the practice of medicine in the later years. (Rafique, 2014)\u003c/p\u003e \u003cp\u003eHorizontal integration (HI) blends the related basic science disciplines (anatomy, physiology, biochemistry, microbiology, pharmacology, and Pathology). This form of integration is often accomplished by the elimination of departmentally oriented teaching (Adam, 2015). Introducing an integrated curriculum may be considered as one of the major reforms to prepare better physicians for the next century (Jone et al., 2001).\u003c/p\u003e \u003cp\u003eBenefits of Horizontally and Vertically Integrated Teaching System (HAVIS) for the students may include improved motivation; enhanced deep learning; Linking the theory of basic science subjects to clinical practice (Knowledge application); Integrating the knowledge of various basic science subjects; Preparation for clinical practice; smooth transition from basic to clinical years; Becoming Better Future Physicians and Enhanced problem-solving and critical thinking. (Brynhildsen et al.,2002; Malik et al., 2011; Ramnarayan et al., 2010; Dolmans et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1997\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe benefits for the faculty members may include Identification of Curriculum overlapping; Prevention of Curricular hypertrophy and curricular overload; curricular reforms; Logical sequencing of the timetable; Faculty development and Enhanced collaboration between various departments (Kalpana et al.,2011; Tresolini et al., 1994; Blue et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Harden et al., 2000)\u003c/p\u003e \u003cp\u003e Although HAVIS is being practiced in many International Medical universities, various reports have identified that Medical Educationists from all over the world are facing major challenges which leads to the failure of HAVIS, eventually returning to the traditional curriculum (Basukala et al., 2021).The reasons for the failure of HAVIS include: The lack of proper guidelines to formulate and implement the \u0026ldquo;HAVIS\u0026rdquo; curriculum; Lack of Integrated examinations for the students of preclinical years. (Some universities claim to deliver an integrated curriculum, but their examination systems are disintegrated); Lack of valid resources and authentic reading materials for HAVIS for both the teachers and students (Tamimi et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Daly et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWe tried to fill the above-mentioned gaps by designing and implementing a unique model of HAVIS at the College of Medicine IAU, which will not only provide the step wise guidance to formulate the HAVIS curriculum but also aimed in designing and provision of authentic reading materials for HAVIS.\u003c/p\u003e \u003cp\u003eOur study focused on three main objectives:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo collect and analyze the data including students\u0026rsquo; results, and students' and faculty' feedback questionnaires about HAVIS. This can provide us with identification that either HAVIS is better than the traditional curriculum.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo stepwise document the process of designing and implementation of HAVIS. This \u0026ldquo;stepwise guide\u0026rdquo; can be beneficial to medical educators all over the world.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo design \u0026ldquo;Horizontally and vertically integrated Lectures, Tutorials, Exam questions \u0026amp; Study guides\u0026rdquo; for the faculty members and the students of the pre-clinical years.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Materials \u0026Methods","content":"\u003cp\u003eThis observational study was conducted at the College of Medicine IAU. A total of 247 Students of MED-301 including 130 Female\u0026thinsp;+\u0026thinsp;117 Male students were exposed to the unique HAVIS system in the year 2023\u0026ndash;2024.\u003c/p\u003e\n\u003cp\u003eEthical approval was taken form the deanship of scientific research, IAU (IRB Approval # 2024-01-685)\u003c/p\u003e\n\u003cp\u003eThe following steps were taken for the formulation and the delivery of HAVIS at IAU College of Medicine.\u003c/p\u003e\n\u003cp\u003eThe proposed plan of the horizontally and vertically integrated teaching system (HAVIS) was approved by the chairperson and 2nd year 3rd year management committee of the College of Medicine IAU in March 2022. The first step was the formation of committees for various Modules that can work together to achieve this target.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eFormation of 10 Modular committees\u003c/h2\u003e\n \u003cp\u003eFor an effective and efficient delivery of HAVIS, 10 Modular committees were formed. Each modular Committee was headed by an \u0026ldquo;expert and experienced faculty member\u0026rdquo; and included 10\u0026ndash;12 team members from all the basic science departments (Anatomy, Physiology, Biochemistry, Microbiology, Pharmacology, and Pathology). To orient the faculties with the idea of HAVIS a series of training sessions and workshops were conducted. The committees started working in April 2023.\u003c/p\u003e\n \u003cp\u003eThe main purpose of each committee was to deliver their module in a horizontally and vertically integrated manner.\u003c/p\u003e\n \u003cp\u003eEach committee formulated the following documents before the start of their module.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Case-based study guide\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multidisciplinary HAVIS PowerPoint\u003c/p\u003e\n \u003cp\u003e\u0026bull; Multidisciplinary HAVIS Tutorial\u003c/p\u003e\n \u003cp\u003e\u0026bull; HAVIS questions for the exam\u003c/p\u003e\n \u003cp\u003e\u0026bull; HAVIS timetable\u003c/p\u003e\n \u003cp\u003eThese documents were finalized after several meetings and discussions among the team members.\u003c/p\u003e\n \u003cp\u003eFollowing is the \u0026ldquo;Stepwise documentation for the formulation and implementation of HAVIS at IAU\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eA Case-based study guide\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe formulation of a case-based study guide was the first step towards HAVIS system. This guide included 10\u0026ndash;12 common case scenarios related to the specific module. The cases were written by the committee members and were later sent to a clinician for final approval. Later on, every department member added an extended stem with relevance to their subject to each Case. The final study guide with Cases and extended stems was shared with the whole team. The leader ensured that the required cases and the related objectives were being used by all the department members in their lectures and other teaching activities.\u003c/p\u003e\n \u003cp\u003eThese cases and extended stems were also used in the formulation of Multidisciplinary HAVIS sessions, HAVIS tutorials, and integrated questions. In fact, these study guides served as a \u0026ldquo;Primary document\u0026rdquo; for all the teaching activities related to HAVIS.\u003c/p\u003e\n \u003cp\u003eThis study guide also included detailed information of the objectives from all departments to be delivered during the module. Moreover, the mode of delivery and learning strategies for each objective were also identified i.e. lectures, tutorials, labs, and PBL sessions\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMultidisciplinary HAVIS PowerPoint presentation with input from all departments\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe group leader coordinated with the team members and formulated a HAVIS PowerPoint presentation including the 8\u0026ndash;10 most common case scenarios related to their module (Vertical integration). Each case scenario was followed by interactive slides and integrated questions from various departments (Horizontal integration). So, the case scenarios that were already vertically integrated in the lectures of various subjects were now horizontally integrated in the Multidisciplinary HAVIS ppt. At the end of each module, one whole day was designated as a \u0026ldquo;HAVIS DAY\u0026rdquo;. Multidisciplinary HAVIS session\u0026rdquo; was delivered in the first 3 hours of HAVIS Day.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMultidisciplinary HAVIS Tutorial\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe HAVIS tutorial was also designed by close collaboration between various department members of the modular team. It included 4\u0026ndash;6 case scenarios (that were not covered in the multidisciplinary HAVIS ppt). Each case scenario was followed by high-order C2\u0026amp;C3 questions from various departments (Horizontal integration). This tutorial also included information about the reference reading material. The integrated tutorial included multiple assessment methodologies that stimulate critical thinking in the students. e.g. the use of diagrams, fill-in-the-blanks, matching questions, short answer questions, etc.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHorizontally and vertically integrated questions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAn exam was held at the end of each module. Group leader of each module was responsible for the formulation of the blueprint for the exam. 30% of the total questions in the exam were integrated. A separate portion in each exam paper was assigned for integrated questions. Each Integrated question started with a case scenario (vertical integration), followed by 4\u0026ndash;5 high order thinking questions from various departments (horizontal integration). With the help of our modular teams, we were able to formulate more than 300 high quality Integrated questions, which are being successfully utilized in the modular exams at IAU. (All these questions have passed through multiple quality checks; low quality questions were removed from the question banks). (See the sample of an integrated Question in appendix # 1.)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHorizontally and vertically integrated timetable\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe Modular leader was responsible for the formulation of an integrated timetable for their module. The timetable was arranged in a logical sequence, starting with the lectures of Anatomy followed by Physiology, Biochemistry, Microbiology, Pathology and Pharmacology. The PBLs and clinical skills sessions were interwoven at their best possible place to facilitate and enhance vertical and horizontal integration and deep learning. This practice solved many problems related to the sequential organization of the timetable.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eModus operandi of Delivering HAVIS\u003c/h3\u003e\n\u003cp\u003eA clinical scenario was introduced as a trigger at the beginning of the specific theme, and the objectives revolving around that scenario were covered in the next 2 to 3 days. Usually, two case scenarios were covered each week. Almost every lecture on a specific theme started with the same case scenario. However, every department was allowed to make minor modifications in the case, as per their learning objectives. For example, in the case of Gastric ulcer disease, we introduced the case of \u0026ldquo;34-year-old lady Fatma with the symptoms of Gastric ulcer\u0026rdquo;. The Physiology department used this case as a trigger to cover the objective of \u0026ldquo;Physiological functions of stomach\u0026rdquo; The Microbiology department added an extended stem about the \u0026ldquo;laboratory test to diagnose H-Pylori\u0026rdquo;, the Pharmacology department added an extended stem about the \u0026ldquo;management of H-Pylori\u0026rdquo;, Anatomy department added the extended stem about the perforation of the gastric ulcer in order to teach the Anatomy of stomach and related structures. (These cases and triggers were taken from the \u0026ldquo;Case based study guides\u0026rdquo; formulated by the modular teams before the beginning of each module). So, the students of MED-301 were familiarized with the same patient Fatma in their lectures of Physiology, Anatomy, Biochemistry, Microbiology and Pharmacology (vertical integration). Finally, \u0026ldquo;Fatma\u0026rsquo;s Case of Gastric ulcer disease\u0026rdquo; was presented in the \u0026ldquo;Multidisciplinary HAVIS session\u0026rdquo; where students were given an opportunity to connect related topics across different disciplines, resulting in concurrent learning in Anatomy (structure of the stomach), Physiology (functions of stomach), Microbiology (Diagnostic tests for H-Pylori) and Pharmacology (Management of H-pylori).\u003c/p\u003e\n\u003cp\u003eThis approach helped the students to see the interconnectedness of different disciplines and how they contribute to understanding the human body in health and disease.\u003c/p\u003e\n\u003cp\u003eSpecial care was taken to keep a balance between clinical and basic science knowledge. As the purpose of Vertical integration in preclinical years is just to orient the students with the common clinical conditions, and to help them understand the practical application of basic science knowledge. Therefore, a ratio of 30\u0026ndash;70 was taken into consideration, 30% of knowledge should be clinical and 70% should be related to the basic science subjects. Simple cases were formulated where the objectives revolved mostly around the normal structure and functions. (See the sample of \u0026ldquo;Fatmas\u0026rsquo; case of gastric ulcer disease, delivered by HAVIS\u0026rdquo; attached in appendix # 2.)\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eData Analysis\u003c/h2\u003e\n \u003cp\u003eStatistical analysis was performed by SPSS Version 20.\u003c/p\u003e\n \u003cp\u003eThe students and faculty feedback responses were calculated by using Five -point Likert-Type scale. The percentages were analyzed for all the questions.\u003c/p\u003e\n \u003cp\u003eThe comparison of exam results between the HAVIS and the traditional groups was done by Chi-Square Test. P value less than 0.05 was considered as statistically significant.\u003c/p\u003e\n \u003cp\u003eOpen-ended comments of the students and faculty members were qualitatively analyzed, which helped us to identify various strengths and weaknesses of the system.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eExamination and Results\u003c/h2\u003e \u003cp\u003eAn exam was held at the end of each module. We performed a comparative analysis of average examination results between HAVIS and non-HAVIS students. (The Average Exam Grades refer to the Cumulative exam grades of Midterm l+ Midterm2\u0026thinsp;+\u0026thinsp;End of term exam).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTable\u0026nbsp;1\u003c/span\u003e shows the comparison of the exam results of the same group of students when exposed to two different teaching systems, i.e. HAVIS vs Non HAVIS, indicating that HAVIS leads to a statistically significant increase in A and decrease in F grades of the students.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTable\u0026nbsp;2\u003c/span\u003e shows the comparison of exam results between two different groups of students who were exposed to two different teaching systems, i.e. HAVIS vs Non HAVIS. This comparison also showed that the group exposed to HAVIS had a statistically significant increase in B and decrease in the F grades of the students.\u003c/p\u003e \u003cp\u003eThese comparisons indicate that the students exposed to HAVIS system showed a significant decrease in the failure rate in the exams, thereby indicating that HAVIS system may be superior to the traditional curriculum for the students of pre-clinical years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudent and faculty feedback\u003c/h2\u003e \u003cp\u003eAt the end of the year, the students and the faculty members involved in HAVIS filled an online questionnaire. Analysis of the feedback questionnaires helped us to understand the benefits of HAVIS. Moreover, the comments from students and faculty members also provided insights to improve in future.\u003c/p\u003e \u003cp\u003eStudents\u0026rsquo; feedback questionnaire (including 12 questions) was shared with 247 students of MED-201 at IAU. The response rate was 85% as the questionnaire was filled out and returned by 210 students. Responses of the students to the HAVIS questionnaire are summarized in \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTable\u0026nbsp;3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eFaculty feedback questionnaire (including 12 questions) was shared with 40 faculty members who were involved in the designing and implementation of HAVIS at IAU. The response rate was 87.5% as 35 out of 40 faculty members filled and returned the questionnaire. Responses of the faculties to the HAVIS questionnaire are summarized in \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTable\u0026nbsp;4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eBased on the improved exam results and positive feedback from students and faculty members, it was decided by the 2nd year and 3rd year management committee to continue this teaching methodology in future for the students of pre-clinical years at IAU.\u003c/p\u003e \u003cp\u003eWe also received valuable open comments from the students and the faculty members, which helped us improve in future.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOpen comments from faculty members\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe modular leaders should meet frequently to share their experiences with each other.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe training workshops should be frequent.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFormulation of horizontally and vertically integrated questions is a difficult task; it needs further training of the staff.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eOpen comments from students\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe students\u0026rsquo; participation in the HAVIS sessions should be increased.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe students participating in the HAVIS sessions should be provided \u0026ldquo;Appreciation certificates\u0026rdquo;.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe teaching sessions should include online quiz focusing on various aspects of integration.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe use of simulated patients can make vertical integration even more interesting and meaningful.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThere should be practice sessions for integrated questions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSome case scenarios were long and complicated, the cases should be simple and more emphasis should be on basic rather than clinical concepts.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cdiv class=\"BlockQuote\"\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable I. Comparison of Average Exam Results of Class of Med-2022\u003c/b\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e(With and without Horizontal and vertical integration)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage exam grades of MED-2022\u003c/p\u003e \u003cp\u003e(Without HAVIS)\u003c/p\u003e \u003cp\u003e2nd Year exam results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage exam grades of MED-2022\u003c/p\u003e \u003cp\u003e(With HAVIS)\u003c/p\u003e \u003cp\u003e3rd Year exam results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade A\u0026thinsp;=\u0026thinsp;11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade A:22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade B\u0026thinsp;=\u0026thinsp;29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade B\u0026thinsp;=\u0026thinsp;31%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade F: 21.65%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF: 13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThis table shows the comparison of exam results of the \u003cb\u003esame group\u003c/b\u003e of students when exposed to two different teaching systems, i.e. HAVIS vs Non HAVIS.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAverage Exam Grades= Cumulative exam grades of Midterm l+ Midterm2\u0026thinsp;+\u0026thinsp;End of term exam.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHAVIS: Horizontally and vertically Integrated teaching system\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e*P value less than 0.05% was considered statistically significant.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable II. Comparison of average exam results between the Class of MED- 2021(without HAVIS) and MED- 2022(with HAVIS)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage exam grades of class of MED-2021\u003c/p\u003e \u003cp\u003e(Without HAVI S)\u003c/p\u003e \u003cp\u003e3rd year exam results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage exam grades of class of MED-2022\u003c/p\u003e \u003cp\u003e(With HAVI S)\u003c/p\u003e \u003cp\u003e3rd year exam results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade A\u0026thinsp;=\u0026thinsp;19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade A:22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade B\u0026thinsp;=\u0026thinsp;16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade B\u0026thinsp;=\u0026thinsp;31%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u0026thinsp;=\u0026thinsp;17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF: 13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThis table shows the comparison of exam results between two different groups of students who were exposed to two different teaching systems, i.e. HAVIS vs Non HAVIS.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAverage Exam Grades= Cumulative exam grades of Midterm l+ Midterm2\u0026thinsp;+\u0026thinsp;End of term exam.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHAVIS: Horizontally and vertically Integrated teaching system\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e*P value less than 0.05% was considered statistically significant.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable III\u003c/b\u003e:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStudents feedback on \"Horizontally and vertically integrated teaching system\u0026rdquo; at IAU\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e(N\u0026thinsp;=\u0026thinsp;210 students)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003cp\u003e\u0026amp; Strongly Agree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003cp\u003e\u0026amp;\u003c/p\u003e \u003cp\u003eStrongly disagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUncertain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that HAVIS is better than traditional teaching system?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter the implementation of HAVIS, have you noticed an improvement in the sequence of the lectures in the timetable?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes vertical integration (adding cases in lectures) help you in better understanding of concepts?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes horizontal integration (integration between various departments) help you to integrate knowledge of different basic science subjects?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes HAVIS help you to link the theory to clinical practice?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes HAVIS provoke your critical thinking?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes HAVIS promote deep and meaningful learning?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that the clinical knowledge gained during HAVIS would be helpful to you in future clinical years?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that HAVIS can help you to become better physicians?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that the integrated questions provoked your critical thinking?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you find the \u0026ldquo;Horizontally and vertically integrated sessions\u0026rdquo; at the end of each module, interesting?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that HAVIS should continue in future?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHAVIS\u003c/strong\u003e \u003cp\u003eHorizontally and vertically Integrated teaching system\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe values in the table are the responses of Students in percentages\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable IV\u003c/b\u003e:\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFaculty feedback on \"Horizontally and vertically integrated teaching system\u0026rdquo; at IAU\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e(N\u0026thinsp;=\u0026thinsp;40)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003cp\u003e\u0026amp; Strongly Agree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003cp\u003e\u0026amp;\u003c/p\u003e \u003cp\u003eStrongly disagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUncertain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIs HAVIS better than traditional teaching system?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes HAVIS helped in the better sequencing of the lectures and improvements in the timetable (e.g. delivery of Microbiology and Pharmacology lectures after the delivery of Anatomy and physiology\u003c/p\u003e \u003cp\u003electures)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes vertical integration (adding cases in lectures) help the students in better understanding of concepts?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes horizontal integration (integration between various departments) help the students to integrate knowledge of different subjects?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes horizontal integration (integration between various departments) improve the interaction and coordination between various departments?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes HAVIS help the students to link the theory to clinical practice?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes HAVIS provoke critical thinking in the students?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoes HAVIS promote deep and meaningful learning for the students?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that the clinical knowledge gained during HAVIS would be helpful to the students in their future clinical years?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that HAVIS can help our students to become better physicians?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you feel that students\u0026rsquo; participation in your lectures have improved by introducing vertical integration?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that student\u0026rsquo;s assessment by vertically and horizontally integrated questions stimulates high order thinking?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that HAVIS helped you in your personal growth as a teacher?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think that HAVIS should continue in future?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHAVIS\u003c/strong\u003e \u003cp\u003eHorizontally and vertically Integrated teaching system\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe values in the table are the responses of faculty members in percentages.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe implementation of the HAVIS has created a transformative impact on the students and faculty members at IAU. Our results demonstrate that HAVIS system has significantly enhanced the academic performance of the students. Moreover, this system has also received overwhelming support and positive feedback from both students and faculty members of IAU.\u003c/p\u003e \u003cp\u003eThe core finding of our study was that after the implementation of HAVIS, there was a statistically significant increase in grades (A and B) and a notable decrease in failure percentage (F grades). Our findings are in line with the study conducted by Brauer and Ferguson, which highlights that an integrated teaching approach helps the students to relate their knowledge effectively, resulting in the long-term retention of knowledge and improved performance in exams (Allouch et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) Moreover, the study results of Al-Qahtani et al. indicated that the students exposed to an integrated curriculum showed high exam scores and low failure rates as compared to the students of a traditional curriculum (Brauer et al., 2015). These findings are in accordance with our study results where we found a statistically significant decrease in the failure rates of the students after the implementation of HAVIS. These findings indicate that when students are provided with an opportunity to link anatomy, Physiology, Biochemistry, Microbiology and Pharmacology (horizontal integration) with clinical cases (vertical Integration), there is a shift from rote memorization to critical thinking and knowledge application which results in improved cognition and better exam performance.\u003c/p\u003e \u003cp\u003eIn addition, it has been observed that the medical students exposed to HAVIS systems show a higher passing rate in National and international post-graduation exams. As the horizontal and vertical integration promotes deep understanding and meaningful learning, thereby forming stronger cognitive connections and enhancing the abilities to retain information for a longer period of time (Dahle et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFeedback reports from our students indicated that HAVIS is better than traditional teaching system. These findings were similar to the study results of Khalil et al. where 82% of their student\u0026rsquo;s favored integration over traditional curriculum, that is very close to our reported student satisfaction rate (85%) (McLean et al., 2016). In addition, our faculty's positive response (95% favoring HAVIS) is also consistent with international literature. A review article by Muller et al. has pinned down that although integrated curriculum requires more planning and greater collaborative efforts, its benefits are much higher than a traditional curriculum (Khalil et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study findings have revealed that although the designing and implementation of HAVIS system is challenging and demanding compared to the traditional system, but it provides multiple long-term benefits to the students and the faculty members.\u003c/p\u003e \u003cp\u003eOne of the major advantages of HAVIS system is that it helps to Link the theory of basic science subjects to clinical practice (Knowledge application). (Agreed by 93% faculty and 91% of students at IAU). The early exposure of students to clinical scenarios provides them with immediate opportunities to apply basic sciences knowledge relevant to real world patients. Our results mirror the findings of Dahle et al. who reported that students in a vertically integrated curriculum are better prepared for clinical rotations (Brauer et al., 2014). HAVIS system provides an early exposure of the students to the case scenarios and vignettes which allows them to connect what they learned to patient diagnosis and management. This clinical application of Basic science knowledge not only helps in a smooth transition from basic to clinical years but also prepares the students for the future clinical practice resulting in producing better future Physicians. (These findings were supported by 91% faculty and 92% of students at IAU).\u003c/p\u003e \u003cp\u003eAs the HAVIS system was designed for pre-clinical years, therefore the challenge faced by our faculty members was to formulate simple and relevant case scenarios that could be used as the triggers in the lectures with more emphasis on basic rather than clinical teaching. Despite tremendous efforts by the modular teams, we still received comments from the students indicating that some of the vignettes were complex and irrelevant and the facilitators spent more time in explaining the clinical rather than the basic science concepts. The study of Rafique \u0026amp;Hardey et al. also highlights this challenge and emphasizes keeping a balance between basic and clinical knowledge. They proposed a 30:70 ratio of clinical/basic science knowledge, and recommended keeping the case scenarios simple and understandable for the students of pre-clinical years (Muller et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Rafique et al., 2014). Our students also suggested to use simulated patients and making use of Artificial intelligence (AI), to make vertical integration \"more meaningful\u0026rdquo; and \u0026ldquo;interesting\u0026rdquo;. Some faculties did use simulated patients, but this practice was limited. Therefore, it is recommended to arrange frequent AI training programs and workshops for the faculty members, which can help them to save hundreds of hours in manual drafting of cases while maintaining high educational standards.\u003c/p\u003e \u003cp\u003eAnother major benefit of HAVIS system is that it serves as a diagnostic tool for the curriculum itself and helps to identify overlaps, repetitions, and gaps. Held et al. demonstrated that an integrated curriculum not only helps in the logical sequencing of the timetable (Ensuring that Physiology precedes Microbiology and Pharmacology) but also identifies the redundant information across departments which aids in preventing curricular hypertrophy and curricular overload(Hardy et al., 2011). Harden (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2000\u003c/span\u003e), the pioneer of the \"Integration Ladder,\" also spotlighted that integration in medical curriculum is essential to prevent the \"information explosion\" which ultimately ensures that only the most relevant, \"must-know\" content is prioritized (Held et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Our study results have also elaborated the similar findings. The faculty members at IAU have reported that implementation of the HAVIS system helped them to: Identify repetition and overlapping of topics between various subjects; Recognize some important missing topics in the curriculum and formulate a logically sequenced timetable. These changes were highly appreciated by the students and teachers at IAU. (90% Students and 92% Teachers noticed an improvement in the curricular delivery and timetable sequence after the implementation of HAVIS).\u003c/p\u003e \u003cp\u003eOne of the main strengths as well as the biggest challenge of our HAVIS system was the formulation of horizontally and vertically integrated assessments (HAVIA). HAVIA is considered as a \"gold standard\" for assessment in modern medical education, yet it remains one of the most difficult transitions for faculty to make. While many institutions claim to have adopted an 'integrated' curriculum, a discrepancy often exists between delivery and assessment. Many such programs remain 'integrated in name only,' where lectures are grouped by organ system, but examinations remain dis-integrated and segregated into departmental blocks. And this is considered as one of the biggest reasons for failure of HAVIS (where integrated curriculums eventually revert to traditional teaching patterns because the assessment methods never truly changed) (Harden et al., 2000).\u003c/p\u003e \u003cp\u003eKeeping these facts in mind, we placed special efforts to design \u0026ldquo;Integrated assessments\u0026rdquo; for each module. A complete section was dedicated to integrated questions in each Modular exam (Containing 30\u0026ndash;40% of integrated questions). However, this transition was not without hurdles; the primary challenges identified include the logistical difficulty of inter-departmental coordination, faculty training and the significant time investment required to draft high-quality, validated integrated items (Gleason et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) It has been found that \"curriculum drift\" occurs when faculty members are not well trained in writing multi-step vignettes and they may revert to what they know: testing isolated facts within their own specialty (Kulasegaram et al., 2019). In order to avoid this problem, we conducted several training workshops for the Modular leaders and the faculty members of each team. The knowledge and skills gained during these training sessions were beautifully implemented by our faculty members in their modules and 89% of the teaching staff reported that HAVIS helped you in their personal growth as a teacher.\u003c/p\u003e \u003cp\u003eAnother strength of our study is that we have formulated\u0026rdquo; Horizontally and vertically Integrated study guides\u0026rdquo; for the medical educators and the students of preclinical years. (Kindly refer to the methodology section for the details). Because various reports have indicated that a major challenge faced by the medical students and the medical educators all over the world is the unavailability of authentic reading material for an integrated curriculum. In the current HAVIS practice, the students just have to rely upon the notes or PowerPoint presentations formulated by the faculty members (Schmidt et al., 2007; Atta et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). We have tried to fill this major gap by providing \u0026ldquo;Horizontally and vertically integrated case-based study guides\u0026rdquo; which can be a breakthrough and a valuable tool for case-based teaching in basic medical sciences at a global level.\u003c/p\u003e \u003cp\u003eBased on our study results we can summarize that HAVIS system promotes deep learning; increases student motivation by showing clinical relevance; improves exam performance; helps in faculty development; streamlines the curriculum; helps in the smooth transition from basic to clinical years and produces the physicians who are not just knowledgeable, but clinically ready. But at the same time HAVIS is associated with various challenges including high faculty workload; faculty resistance; intense inter-departmental collaboration; difficulty in standardizing difficulty levels across disciplines; potential for \"fragmented\" and non-integrated assessments.\u003c/p\u003e \u003cp\u003eThese problems can be solved by the formulation of dedicated \u0026ldquo;Modular committees\u0026rdquo; for each body system. Each committee should be headed by \u0026ldquo;subject champions\u0026rdquo; from the basic and clinical science. Each committee should act as a quality control hub for the formulation and delivery of the content related to their module in a perfect way. In addition, multiple workshops should be conducted to train the faculty members on various aspects of integration and frequent meetings of the committee members should be held to ensure the horizontal links between subjects.\u003c/p\u003e \u003cp\u003eMoreover, we also recommend using of \u0026ldquo;Stepwise guide for designing the HAVIS curriculum\u0026rdquo;, \u0026ldquo;HAVIS study guides\u0026rdquo; and \u0026ldquo;Digital item banks\u0026rdquo; to reduce the long term workload without compromising high quality standards.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHAVIS is an innovative and effective teaching methodology that stimulates deep and meaningful learning resulting in improvement in exam results.\u003c/p\u003e \u003cp\u003eMoreover, we have documented the process of designing and implementation of HAVIS at IAU in a stepwise manner in the methodology section. This \u0026ldquo;stepwise guide\u0026rdquo; can be beneficial to medical educators all over the world.\u003c/p\u003e \u003cp\u003eIn addition, we have formulated \u0026ldquo;Horizontally and vertically integrated Study guides\u0026rdquo; for the faculty members and the students of the pre-clinical years. These documents can be a valuable tool for case-based teaching in basic medical sciences at National and International level.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflicts of interest are declared by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData transparency Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that all data and materials comply with field standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was taken form the deanship of scientific research, IAU (IRB Approval # 2024-01-685).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProf. Nazish Rafique \u0026amp; Prof Ahmed AAlSunni have contributed to the Conception/design of the research, \u0026nbsp;Collection of data and writing the manuscript. Dr. Ayad Salem, Prof. Rabia Latif and Dr. \u0026nbsp;Khalood AlKhater helped in data collection and drafting \u0026nbsp;the methodology and discussion section. \u0026nbsp;Drs. Reem Aldossary, Yousaf Begum and Lubna Ibrahim AlAsoom helped in the data collection, data analysis and writing the results section. All the authors have read the final manuscript and gave the final approval. All the authors also Agree to be held accountable for the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdam C, Diehl L, Reader L, Hamosh A, Bodurtha JN (2015) Horizontal integration of OMIM across the medical school preclinical curriculum for early reinforcement of clinical genetics principles. Genet Sci 17(2):158\u0026ndash;163\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllouch S, Ali RM, Al-Wattary N et al (2024) Tools for measuring curriculum integration in health professions\u0026rsquo; education: A systematic review. 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J Taibah Univ Med Sci 9(4):282\u0026ndash;288\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamnarayan K, Hande S (2010) Thoughts on self-directed learning in medical schools: Making students more responsible. Johns Hopkins University\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt HG, Rikers RM (2007) How expertise develops in medicine: Knowledge encapsulation and illness script formation. Med Educ 41(12):1133\u0026ndash;1139\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTamimi HE, Nurhussen A, Rohra D, Ouban A, Alshadoukhy A, Alkattan W, Kemahlı S (2018) Vertical integration in clinical years of medical education. Educ Med J (TED) 17(52):27\u0026ndash;34\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTresolini DA, Shugars DA (1994) An integrated health care model in medical education: Interviews with faculty and administrators. Acad Med 69(3):231\u0026ndash;236\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWijnen-Meijer M, van den Broek S, Koens F, ten Cate O (2020) Vertical integration in medical education: The broader perspective. BMC Med Educ 20(1):20\u0026ndash;24\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Imam Abdulrahman Bin Faisal University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Horizontal Integration, Vertical integration, Horizontally and vertically integrated teaching system (HAVIS).","lastPublishedDoi":"10.21203/rs.3.rs-9426343/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9426343/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMedical education is shifting from traditional subject-based models to integrated approaches. But, many institutions struggle with implementation due to a lack of proper guidelines eventually returning to the traditional curriculum.We tried to fill these gaps by designing and implementing a unique model of Horizontally and Vertically Integrated Teaching System (HAVIS)that aimed to: Document a stepwise guide for HAVIS implementation \u0026amp;Develop multidisciplinary teaching materials and integrated examination tools.This observational study involved 50 faculty members and 247 third-year medical students at IAU during 2023\u0026ndash;2024 academic year. Ten modular committees, comprising experts from all basic science departments, were formed. The implementation followed a structured \"Stepwise Guide\". Each modular team formulated a study guide that featured 10\u0026ndash;12 clinical scenarios with horizontally and vertically integrated discipline-specific \"extended stems\". Each module ended with an exam including 30\u0026ndash;40% of horizontally and vertically integrated questions.\u003c/p\u003e \u003cp\u003eIn a cohort comparison, students exposed to HAVIS showed a statistically significant increase in the \u0026ldquo;A\" grades (from 11% to 22%) and decrease in failure (F) rates (from 21.65% to 13.5%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In addition, 85% of students and 95% of faculty members believed that HAVIS is better than traditional teaching system and should be continued in future. Therefore, we conclude that HAVIS is an effective teaching methodology that stimulates deep and meaningful learning.\u003c/p\u003e \u003cp\u003eMoreover, we have designed a \u0026ldquo;Stepwise integrated curriculum guide\u0026rdquo; and \u0026ldquo;Horizontally and vertically integrated modular Study guides\u0026rdquo; which can serve as valuable tools for case-based teaching in pre-clinical years at National and International level.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e","manuscriptTitle":"Designing and implementing a unique model of horizontally and vertically integrated teaching methodology for the students of pre-clinical years","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-16 05:25:27","doi":"10.21203/rs.3.rs-9426343/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"064807ab-db08-4869-baa1-557306557ee3","owner":[],"postedDate":"April 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-16T05:25:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-16 05:25:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9426343","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9426343","identity":"rs-9426343","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}