Medical Teacher

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Breaking down barriers and building up facilitators

of lecture free curriculum in medical education: An
interpretive structural modeling

Sahar Karami, Mohammad Shariati, Dean Parmelee, Hooman Shahsavari,

Akram Sadeghian, Roberto Baelo Alvarez, Abir Zitouni & Maryam Alizadeh

To cite this article: Sahar Karami, Mohammad Shariati, Dean Parmelee, Hooman Shahsavari,
Akram Sadeghian, Roberto Baelo Alvarez, Abir Zitouni & Maryam Alizadeh (30 Apr
2024): Breaking down barriers and building up facilitators of lecture free curriculum
in medical education: An interpretive structural modeling, Medical Teacher, DOI:
10.1080/0142159X.2024.2343025

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MEDICAL TEACHER
https://doi.org/10.1080/0142159X.2024.2343025

Breaking down barriers and building up facilitators of lecture free curriculum

in medical education: An interpretive structural modeling
Sahar Karamia , Mohammad Shariatib , Dean Parmeleec , Hooman Shahsavarid , Akram Sadeghiane
, Roberto Baelo Alvarezf , Abir Zitounif and Maryam Alizadehg
a
Medical Education Department, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; bDepartment of Medical
Education and Department of Community Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; cPsychiatry
& Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA; dMedical-Surgical Nursing Department, School of
Nursing and Midwifery, Tehran University of Medical Sciences (TUMS), Tehran, Iran; eSchool of Medicine, Education Development Office
(EDO), Isfahan University of Medical Sciences, Isfahan, Iran; fDepartment of General and Specifics Didactics and Educational Theory,
Faculty of Education, Universidad de Le
on, Le
on, Spain; gDepartment of Medical Education, School of Medicine and Health Professions
Education Research Center, Tehran University of Medical Sciences (TUMS), Tehran, Iran

ABSTRACT ARTICLE HISTORY

Introduction: The field of medical education has seen a growing interest in lecture free curricu- Received 8 November 2023
lum. However, it comes with its own set of challenges and obstacles. In this article, we aim to Accepted 10 April 2024
identify the prerequisites, facilitators, challenges, and barriers of lecture-free curriculum in medical
KEYWORDS
education and examine their interrelationships using interpretive structural modeling (ISM)
Active learning; lecture-free
technique. curriculum; interpretive
Methods: In this mixed-method study initially, we performed a scoping review and semi-structured structural modeling;
interviews and determined the main prerequisites, facilitators, challenges, and barriers of lecture- medical education
free curriculum in medical education using qualitative content analysis approach. The interrelation-
ships among these components were investigated using ISM. Therefore, self-interactive structural
matrices were formed, initial and final reachability matrices were achieved, and MICMAC analysis
was conducted to classify the factors.
Results: Finally, two ISM models of prerequisites and facilitators with 27 factors in 10 levels and
challenges and obstacles with 25 factors in eight levels were developed. Each of the models was
divided into three parts: key, strategic, and dependent factors. ‘Providing relevant evidence regard-
ing lecture free curriculum’ emerged as the most important prerequisite and facilitator, and
‘insufficient support from the university’ was identified as the most critical barrier and challenge.
Conclusions: The study highlights the significant importance of lecture-free curriculum in medical
education and provides insights into its prerequisites, facilitators, challenges, and barriers. The find-
ings can be utilized by educational managers and decision-makers to implement necessary
changes in the design and implementation of lecture-free in medical education, leading to more
effective improvements in the quality and success of education.

Introduction
In recent years, there has been an increased focus on lec-
ture-free curriculum to medical education due to the limita-
tions of traditional lectures in promoting essential clinical
reasoning skills. Active learning approaches that incorpor-
ate principles of neuroscience, such as retrieval-based
learning, spaced repetition, and frequent low-stakes assess-
ments, have been developed to replace traditional meth-
ods. These approaches, including team-based learning,
problem-based learning, and peer instruction, support
deep learning of curricular content and foster non-cogni-
tive skills as well as, leadership, critical thinking, and team-
work, which are crucial for healthcare professionals
(Parmelee et al. 2020).
While the term ‘lecture-free’ is relatively new, the shift
toward student-centered curricula has been underway since
the 1960s. McMaster University’s implementation of prob-
lem-based learning in 1969 marked a significant milestone in
Practice points

Providing strong and credible evidence to faculty
and students regarding the benefits and experien-
ces of implementing a lecture-free curriculum can
lead to an increase in the adoption of this type of
education.

Comprehensive institutional support, allocating a
separate budget, and aligning the rules to the lec-
ture-free curriculum can address the most signifi-
cant challenges and barriers to its
implementation.
this movement (Spaulding 1969). Subsequently, other educa-
tional institutions, including the University of Maastricht,
Newcastle, Hawaii, Harvard, Sherbrook, and Dalhousie
decided to transform their entire curricula into problem-
based learning, though lectures were reduced in number

CONTACT Maryam Alizadeh malizadeh@tums.ac.ir, alizade.aban@gmail.com Department of Medical Education, School of Medicine and Health
Professions Education Research Center, Tehran University of Medical Sciences (TUMS), Tehran, Iran
Supplemental data for this article can be accessed online at https://doi.org/10.1080/0142159X.2024.2343025.
ß 2024 Informa UK Limited, trading as Taylor & Francis Group
2 S. KARAMI ET AL.
they were not eliminated (Colvin and Wetzel 1989; Kolars
et al. 1997).
Following the introduction of lecture-free (really, lecture
reduction) curriculum, some criticisms have been raised,
including the difficulty for both professors and students to
distance themselves from their traditional roles in a
teacher-centered environment (Heise and Himes 2010;
Drew and Mackie 2011). This shift in roles is perceived as a
challenge for professors, as they are expected to demon-
strate their expertise in roles such as ‘motivator, guide,
coach, and collaborator’ (Aksit et al. 2016). In some studies,
resistance to change during the process of modifying
teaching methods has been mentioned. For example, some
professors criticized the modification of traditional teaching
methods, believing in the powerful impact of conventional
teaching and being unprepared to utilize student-centered
teaching due to inadequate training (Alhawiti 2023).
Other barriers mentioned include the culture of student
passivity, lack of motivation, and self-confidence. The most
common barrier is the culture of student passivity, as stu-
dents are accustomed to listening to lectures and prefer it
as a simpler learning method (Des Marchais et al. 1992;
Des Marchais 1993; Alhawiti 2023). This preference arises
because they expect exam questions to come from lec-
tures. Students often perceive a higher workload in courses
with active teaching methods compared to lecture-based
courses, primarily due to the significant time required for
sufficient pre-class self-study (Mann and Kaufman 1995).
Additionally, students express concerns about final exams,
since they believe that active classrooms do not adequately
prepare them for these exams.
To advance the goal of a lecture-free curriculum, univer-
sities worldwide, including Sherbrooke, Dalhousie, Harvard,
McMaster, and New Mexico, have conducted studies.
Implementing this change at the institutional level necessi-
tates careful attention to prerequisites and facilitators, as
well as overcoming obstacles. Key prerequisites and facilita-
tors identified by these universities include diagnosing cur-
riculum issues, comprehensive development programs for
educators emphasizing student-centered education, a
revised reward system considering instructors’ time and
effort, motivation-building for adopting active teaching
methods, external evaluation by foreign consultants, visits
to successful universities, regular newsletters to keep stake-
holders informed, strong support from institutional leaders,
knowledge-sharing sessions among instructors, and revised
promotion and appointment regulations based on partici-
pation in the revised program (Colvin and Wetzel 1989;
Kaufman et al. 1989; Des Marchais et al. 1992; Des
Marchais 1993; Mann and Kaufman 1995; Barrows 2000).
While various universities worldwide have paid attention
to implementing active teaching and learning methods at
the institutional level, a comprehensive and practical model
for adoption in medical universities has not been pre-
sented. One of the techniques recently employed to iden-
tify and prioritize prerequisites and barriers is the
interpretive structural modeling (ISM) method, which has
been used in fields such as safety, health, environmental
management, risk control design, and education, including
medical education (Sadeghian et al. 2020; Sarikhani et al.
2020). Furthermore, it can develop structural and mutual
relationships between system components and determine
the level of these factors based on their driving power or
dependency (Attri et al. 2013).
This study was conducted with two objectives: (1) iden-
tifying the prerequisites, facilitators, challenges, and barriers
of lecture-free curriculum in medical education and (2)
determining the mutual structural relationships among
these components and identifying the most dominant fac-
tors using the ISM technique.
Methods
Context
The participants of this study were managers, educators,
and students of the Doctor of Medicine (MD) program at
Tehran University of Medical Sciences (TUMS). TUMS is a
public university in Iran, and its MD curriculum includes
seven years of study in four stages: basic sciences (2 years),
physiopathology and symptomatology (1 year), internship
(2.5 years), and clerkship (1.5 years), with the basic sciences
and physiopathology and symptomatology stages being
considered the pre-clinical phase of this program. TUMS
started using team-based learning (TBL) as a core instruc-
tional strategy in their 15% of the classes during pre-clin-
ical phase of new curriculum in 2011, and, as of 2020,
about 30% of its classroom time is lecture-free with the
remainder being interactive within a lecture structure. It
has transformed some of its classrooms into ‘active learn-
ing’ spaces and continues to transition to a ‘lecture-free’
status (Mortaz Hejri et al. 2018; Parmelee et al. 2020).
Design
This article is a sequential mixed-methods research registered
with the code IR.TUMS.MEDICINE.REC.1400.1163 at TUMS and
has been ongoing since 2020. In the qualitative phase of this
study, the scoping review method and interviews were used
to extract the prerequisites, facilitators, challenges, and bar-
riers of implementing lecture-free curriculum. Subsequently, in
the quantitative phase, the ISM technique was employed to
rank the identified influential factors in the adoption of lec-
ture-free curriculum and provide a more comprehensive
understanding of the concept employed.
ISM is a systems design method introduced by Warfield
(1974). ISM is a technique for determining the interrelation-
ships among specific variables that describe a subject. This
method elucidates the order and direction of complex rela-
tionships among elements of a system and develops structural
and mutual relationships among the components of a system.
It can also determine the levels of these factors based on their
driving power and dependency. The comprehensibility for a
wide range of users, coherence in combining expert opinions,
and applicability in studying complex systems composed of
multiple components are among the key advantages of the
ISM. ISM involves seven stages which we followed to conduct
our analysis (Latif and Ghani 2023):
Step 1: Identification of prerequisites, facilitators,
challenges, and barriers of lecture-free curriculum
The first step in ISM involves identifying elements relevant
to the issue. In this study, these variables were obtained

through scoping review and semi-structured interviews.
Due to their extensive nature, the results of this phase will
be reported in another manuscript, and in this paper, we
provided a brief overview of this qualitative phase.
A. Scoping review
First, we conducted a scoping review to identify the
prerequisites, facilitators, challenges, and barriers of lec-
ture-free curriculum. We searched four online databases,
including PubMed, Scopus, Web of Science, and ERIC to
answer the question, ‘What are the prerequisites, facilita-
tors, barriers, and challenges of implementing lecture-free
curriculum in medical universities?’ The articles were
selected based on three main criteria of scoping review
studies. In this regard, we considered the prerequisites,
facilitators, barriers, and challenges of lecture-free curricu-
lum in medical education in terms of population, concept,
and context (PCC). Appendix A (Supplementary material)
presents the search strategy. Two researchers (SK, MA)
independently screened the retrieved articles at three lev-
els, including title, abstract, and full text based on the
inclusion criteria (Appendix B, Supplementary material). The
study focused on articles related to the development of
active teaching and learning methods within medical edu-
cation institutions. These articles were required to be avail-
able in English. Excluded were articles related to active
teaching and learning methods in non-medical educational
institutions or those specifically addressing patient
education.
In all stages of screening, a third researcher reviewed
cases of disagreement. Subsequently, to clarify the factors
influencing lecture-free curriculum, we used conventional
qualitative content analysis. Conventional content analysis
is a research method used to describe a phenomenon,
such as ‘a lecture-free curriculum in medical universities.’
This method is appropriate when there is limited existing
theory or research literature on the phenomenon.
Researchers avoid using preconceived categories and
instead allow the categories to emerge from the data.
Many qualitative methods share this initial approach to
study design and analysis (Lundman and Graneheim 2004).
Initially, we identified the initial codes for the prerequi-
sites, facilitators, barriers, and challenges of lecture-free cur-
riculum. Then, we performed interpretive analysis of the
initial codes to categorize and subcategorize them.
B. Semi structured interview
To enhance the robustness of the study and incorporate
influential factors in the development of lecture free from
the perspective of university managers and medical school
administrators, preclinical faculty members, and medical
students, we utilized the semi-structured interviews. The
interview questions were designed based on the results of
content analysis and the roles of the interviewees.
The research team agreed on the questions, and the
participants chose the time and location of the interviews.
Initially, interviewees were asked: ‘Can you share your
experiences in managing, teaching, or attending lecture-
free curriculum?’ Subsequently, based on their responses,
probing questions were posed to gain insights into partici-
pants’ experiences and to clarify their answers. During the
MEDICAL TEACHER 3
probing questions, we aimed to extract prerequisites, facili-
tators, challenges, and obstacles related to the develop-
ment of lecture-free curriculum based on interviewees’
experiences, or in other words, factors that played a role in
achieving or not achieving desired outcomes (Appendix C,
Supplementary material).
Directed content analysis was used to assign new codes
to existing categories and subcategories that were estab-
lished from the review, or new categories were created as
needed. This process helped shape the subsequent inter-
views accordingly. The interviews continued until data sat-
uration was achieved. To ensure the study’s credibility,
criteria from Guba and Lincoln were employed in the quali-
tative study (Patton et al. 1983).
Questionnaires development and expert validation. After
conducting directed qualitative content analysis of the
interviews, using the final subcategories and their corre-
sponding sub-codes, initial and proposed statements were
developed and formulated. To assess the content and face
validity of the questionnaires, they were presented to 13
medical education experts (outside the research team) with
experience in active learning teaching methods and a back-
ground in medical education. The qualitative face validity
of the questionnaires was evaluated in terms of their
appearance and clarity, and the questions were examined
for their legibility and comprehensibility. The content valid-
ity of the questionnaires was assessed from two aspects:
relevance and clarity index. The content validity index (CVI)
assessment was carried out based on Waltz and Bausell cri-
teria. The experts were asked to rate the relevance, simpli-
city, and clarity of each item in the questionnaire using a
four-part Likert scale (e.g. for relevance: very relevant, rele-
vant, somewhat relevant, and not relevant). Then, the CVI
score for each item in the questionnaires was calculated by
dividing the number of experts who rated the item with a
score of 3 or 4 by the total number of experts. An item
with a CVI score of 0.79 or higher was considered accept-
able for inclusion based on the CVI score (Waltz and
Bausell 1981).
For calculating the content validity ratio (CVR), Lawshe’s
formula was used (Lawshe 2006). The experts were asked
to classify each question on a three-point Likert scale as
‘essential,’ ‘useful but not essential,’ or ‘not essential.’ Then,
the CVR was calculated using the following formula.
According to Lawshe’s table, a CVR value of 0.54 was con-
sidered acceptable for a panel of 13 experts in this study.
Therefore, any item with a calculated CVR value less than
0.54 was excluded from the questionnaire. Finally, suitable
items were formulated based on the explanation and defin-
ition of the extracted factors from the content analysis. The
results of the content validity stage in the questionnaire for
28 items of prerequisites and facilitators, considering the
average CVR of 0.86 and the CVI of 0.96, led to the devel-
opment of a 27-item questionnaire (Appendix F,
Supplementary material). Similarly, the results of the con-
tent validity stage in the questionnaire for 20 items of bar-
riers and challenges, considering the average CVR of 0.92
and the CVI of 0.98, resulted in a 25-item questionnaire.
Based on expert suggestions, some items were divided into
two separate items, thus adding five items to the previous
ones (Appendix G, Supplementary material).
4 S. KARAMI ET AL.
Step 2: Formation of the interactive structural matrix
In the second step, the statements identified in the ques-
tionnaires of the previous step were summarized and
placed in row and column of two paired comparison ques-
tionnaires to compare the influence and impact of each of
these factors in pairs. Subsequently, a session was con-
ducted with the participation of 10 experts, including six
managers with a minimum of 4 years of management
experience at the university or faculty level in the field of
medical education, and four faculty members with 5 years
of teaching experience and at least one publication, lec-
ture, research project, or thesis supervision around teaching
and learning methodologies or medical education. They
were asked to compare pairwise the influence and impact
of each factor listed in the row and column of the paired
comparison questionnaires and mark them exclusively in
the upper triangle of the main diagonal of matrix, accord-
ingly with the designated letters as guided by the instruc-
tions. The reason for this approach is that the inverse
relationships between components can be inferred from
the upper triangle of the main diagonal of matrix, and
completing the upper triangle suffices (Appendices H and I,
Supplementary material).
After completing the pairwise comparison question-
naires by the experts with letters A, V, O, and X, self-struc-
tured interaction matrices (SSIMs) were developed. In these
matrices, the influence of factors on each other is observ-
able (Appendices H and I, Supplementary material). The
rules of conceptual relationships in forming a SSIM are as
follows: if component i influences component j, the symbol
V is selected. If component j influences component i, the
symbol A is selected. If components i and j influence each
other, the symbol X is chosen, and if components i and j
are unrelated, the symbol O is selected.
As multiple experts completed the questionnaires in this
study, the frequency of letters ‘A,’ ‘V,’ ‘O,’ and ‘X’ was calcu-
lated for each cell in the matrices. The letter with the high-
est frequency (mode) was considered as the final letter for
that cell. After performing this process for all cells in the
matrices, the final self-interaction matrices were obtained
(Appendices H and I, Supplementary material).
Step 3: Formation of the initial reachability matrix
In this stage, the initial reachability matrix (Appendices J
and K, Supplementary material) is formed by converting
the symbols of the SSIM matrix (Appendices H and I,
Supplementary material) into numerical values between
zero and one. The conversion process was as follows:

If the symbol in cell ij is the letter V, a number 1 is
placed in that cell, and a number 0 is placed in the cor-
responding cell (A cell on the opposite side of the main
diagonal of matrix);

If the symbol in cell ij is the letter A, a number 0 is
placed in that cell, and a number 1 is placed in the cor-
responding cell;

If the symbol in cell ij is the letter X, a number 1 is
placed in that cell, and a number 1 is also placed in the
corresponding cell;

If the symbol in cell ij is the letter O, a number 0 is
placed in that cell, and a number 0 is also placed in the
corresponding cell.
Step 4: Formation of the final reachability matrix
The final reachability matrices were derived from the initial
reachability matrices (IRMs). These matrices were examined
in terms of transferability. Transferability of textual relation-
ships is a fundamental assumption in ISM. For instance, in
the prerequisite matrix, the assumption is that if P1 influen-
ces P2 and P2 influences P19, P20, and P24, then P1 leads
to P19, P20, and P24. Therefore, these relationships were
individually scrutinized for all prerequisites, facilitators, as
well as all challenges and obstacles. Finally, the modified
layers were marked with 1 in both final reachability matri-
ces (Table 1 and 2).
Step 5: Levels partitioning of variables
In this stage, we first obtained separate lists of influencing
and influenced components for each variable. For this pur-
pose, three sets were defined:
1. Reachability set: The reachability set for a specific vari-
able consists of itself, along with other variables that
contribute to its existence; simply put, all the compo-
nents that have a value of 1 in the row corresponding
to the variable of interest.
2. Antecedent set: The antecedent set for each variable
includes itself, along with other variables that have
played a role in their creation; in simpler terms, all the
components that have a value of 1 in the column cor-
responding to the variable of interest.
3. Intersection set: As the name suggests, it comprises var-
iables that are common in both above sets.
Variables whose intersection set is the same as their
reachability set are considered as higher-level variables in
the ISM hierarchy, meaning that these variables have less
influence on other variables. After identifying the highest-
level variable, it was removed from the list of variables.
These iterations continued until the level of all variables
was determined (Table 3 and 4).
Step 6: Construction of interpretive structural
modeling diagrams
In this stage, the desired structural models were drawn
based on the determined levels and the final reachability
matrices. The relationships between variables were repre-
sented using directed arrows.
Step 7: MICMAC analysis (impact matrix cross-
reference multiplication applied to a classification)
In this stage, the degree of driving scores and dependency
of each component were determined:

Driving scores: This indicates the level of impact on
other components and is derived for each component
from the sum of the numbers in each row of the final
reachability matrix.
 MEDICAL TEACHER 5

Table 1. Final reachability matrix for the prerequisites and facilitators of lecture-free curriculum in medical education.
J
P 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Driving
i 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 26
2 0 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 0 1 1 1 1 1 1 1 0 1 21
3 1 1 1 1 1 1 1 1 1 0 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 25
4 0 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 0 1 1 1 1 1 1 1 0 1 21
5 0 0 1 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 10
6 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 26
7 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 10
8 1 1 1 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 13
9 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 0 0 0 11
10 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 27
11 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 26
12 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 26
13 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 0 1 24
14 0 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 0 0 1 1 1 1 1 1 0 1 20
15 1 1 1 1 1 1 1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25
16 0 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 0 0 1 1 1 1 1 1 0 1 20
17 0 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 0 0 1 1 1 1 1 1 0 1 20
18 0 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 1 0 1 1 1 1 1 1 0 1 21
19 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 8
20 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 3
21 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 9
22 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 10
23 1 1 1 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 13
24 0 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 0 0 1 1 0 1 1 1 0 1 19
25 0 1 1 1 1 1 1 1 1 0 1 1 0 1 0 1 1 0 0 1 1 1 1 1 1 0 1 20
26 1 1 1 0 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 1 0 15
27 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 1 12
Dependency 11 19 25 17 21 24 26 27 17 1 16 16 7 16 8 16 17 8 14 27 26 25 26 25 20 8 17

Table 2. Final reachability matrix for the challenges and barriers of lecture-free curriculum in medical education.
J
C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Driving
i 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 14
2 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 13
3 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 1 0 0 0 14
4 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10
5 1 1 0 1 1 1 1 1 1 1 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 12
6 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 13
7 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 1 1 0 0 15
8 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 13
9 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 13
10 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 11
11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 24
12 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 0 0 0 1 1 0 1 19
13 1 1 1 1 1 1 1 1 1 1 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 14
14 1 1 1 1 1 1 1 1 1 1 0 0 0 1 0 1 1 1 0 0 0 1 1 0 0 16
15 1 1 1 1 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 19
16 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 10
17 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 11
18 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 1 1 0 0 15
19 1 1 1 1 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 19
20 1 1 1 1 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 0 1 0 0 18
21 1 1 1 1 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 19
22 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 1 1 0 0 15
23 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 1 1 0 0 15
24 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 11
25 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 1 1 0 1 16
Dependency 23 25 24 25 25 25 25 25 25 25 1 2 3 3 5 22 22 17 5 5 5 15 13 1 3

Dependency: This indicates the susceptibility to be influ- In this analysis, the variables were categorized into four
enced by other components and is derived for each main groups:
component from the sum of the numbers in each col-
umn of the final reachability matrix. 1. Autonomous variables: This group includes compo-
The purpose of the MICMAC analysis was to examine nents with weak drive power and weak dependency.
and analyze the forces of influence and the level of The components in this category operate almost
dependency among the components. This analysis provides independently from the overall system. They have
a graphical representation of the variables based on their minimal impact on other components, and their rela-
driving scores and dependency in structural-interpretive tionships with other components are limited and
modeling (Figures 1 and 2). insignificant.
6 S. KARAMI ET AL.

Table 3. Level partitioning of the prerequisites and facilitators of lecture-free curriculum in medical education.
No. Reachability set Antecedent set Intersection set Level
1 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,13 ,14 ,15 ,16 , 1 ,3 ,6 ,8 ,10 ,11 ,12 ,13 ,15 ,23 ,26 1 ,3 ,6 ,8 ,11 ,12 ,13 ,15 ,23 ,26 8
17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27
2 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,16 ,17 ,19 ,20 1 ,2 ,3 ,4 ,6 ,8 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 , 2 ,3 ,4 ,6 ,8 ,11 ,12 ,14 ,16 ,17 , 6
,21 ,22 ,23 ,24 ,25 ,27 18 ,23 ,24 ,25 ,26 23 ,24 ,25
3 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,13 ,14 ,16 ,17 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 , 6
18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27 16 ,17 ,18 ,20 ,21 ,22 ,23 ,24 ,25 ,26 13 ,14 ,16 ,17 ,18 ,20 ,21 ,22 ,
23 ,24 ,25 ,26
4 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,16 ,17 ,19 ,20 , 1 ,2 ,3 ,4 ,6 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 ,18 , 2 ,3 ,4 ,6 ,11 ,12 ,14 ,16 ,17 ,24 , 5
21 ,22 ,23 ,24 ,25 ,27 24 ,25 ,27 25 ,27
5 3 ,5 ,6 ,7 ,8 ,20 ,21 ,22 ,23 ,24 1 ,2 ,3 ,4 ,5 ,6 ,8 ,10 ,11 ,12 ,13 ,14 ,15 ,16 , 3 ,5 ,6 ,8 ,23 ,24 4
17 ,18 ,23 ,24 ,25 ,26 ,27
6 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,13 ,14 ,15 ,16 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 , 5
17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27 16 ,17 ,18 ,22 ,23 ,24 ,25 ,26 ,27 13 ,14 ,15 ,16 ,17 ,18 ,22 ,23 ,
24 ,25 ,26 ,27
7 3 ,6 ,7 ,8 ,20 ,21 ,22 ,23 ,24 ,25 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 3 ,6 ,7 ,8 ,21 ,22 ,23 ,24 ,25 2
16 ,17 ,18 ,19 ,21 ,22 ,23 ,24 ,25 ,26 ,27
8 1 ,2 ,3 ,5 ,6 ,7 ,8 ,19 ,20 ,21 ,22 ,23 ,24 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 1 ,2 ,3 ,5 ,6 ,7 ,8 ,19 ,20 ,21 ,22 , 1
16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27 23 ,24
9 3 ,6 ,7 ,8 ,9 ,17 ,20 ,21 ,22 ,23 ,24 1 ,2 ,3 ,4 ,6 ,9 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 , 3 ,6 ,9 ,17 ,24 4
18 ,24 ,25
10 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 10 10 10
16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27
11 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,13 ,14 ,15 ,16 , 1 ,2 ,3 ,4 ,6 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 ,18 , 1 ,2 ,3 ,4 ,6 ,11 ,12 ,13 ,14 ,15 , 8
17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27 24 ,25 16 ,17 ,18 ,24 ,25
12 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,13 ,14 ,15 ,16 , 1 ,2 ,3 ,4 ,6 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 ,18 , 1 ,2 ,3 ,4 ,6 ,11 ,12 ,13 ,14 ,15 , 8
17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27 24 ,25 16 ,17 ,18 ,24 ,25
13 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,13 ,14 ,15 ,16 , 1 ,3 ,6 ,10 ,11 ,12 ,13 1 ,3 ,6 ,11 ,12 ,13 9
17 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,27
14 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,16 ,17 ,20 ,21 , 1 ,2 ,3 ,4 ,6 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 ,18 , 2 ,3 ,4 ,6 ,11 ,12 ,14 ,16 ,17 , 6
22 ,23 ,24 ,25 ,27 24 ,25 24 ,25
15 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,15 ,16 ,17 , 1 ,6 ,10 ,11 ,12 ,13 ,15 ,26 1 ,6 ,11 ,12 ,15 ,26 8
18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27
16 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,16 ,17 ,20 ,21 , 1 ,2 ,3 ,4 ,6 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 ,18 , 2 ,3 ,4 ,6 ,11 ,12 ,14 ,16 ,17 , 6
22 ,23 ,24 ,25 ,27 24 ,25 24 ,25
17 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,16 ,17 ,20 ,21 , 1 ,2 ,3 ,4 ,6 ,9 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 , 2 ,3 ,4 ,6 ,9 ,11 ,12 ,14 ,16 ,17 , 6
22 ,23 ,24 ,25 ,27 18 ,24 ,25 24 ,25
18 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,16 ,17 ,18 ,20 , 1 ,3 ,6 ,10 ,11 ,12 ,15 ,18 3 ,6 ,11 ,12 ,18 7
21 ,22 ,23 ,24 ,25 ,27
19 7 ,8 ,19 ,20 ,21 ,22 ,23 ,24 1 ,2 ,3 ,4 ,6 ,8 ,10 ,11 ,12 ,13 ,15 ,19 ,23 ,27 8 ,19 ,23 4
20 3 ,8 ,20 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 3 ,8 ,20 1
16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27
21 3 ,7 ,8 ,20 ,21 ,22 ,23 ,24 ,25 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 3 ,7 ,8 ,21 ,22 ,23 ,24 ,25 2
16 ,17 ,18 ,19 ,21 ,22 ,23 ,24 ,25 ,26 ,27
22 3 ,6 ,7 ,8 ,20 ,21 ,22 ,23 ,24 ,25 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 3 ,6 ,7 ,8 ,21 ,22 ,23 ,25 3
16 ,17 ,18 ,19 ,21 ,22 ,23 ,26 ,25 ,27
23 1 ,2 ,3 ,5 ,6 ,7 ,8 ,19 ,20 ,21 ,22 ,23 ,24 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 1 ,2 ,3 ,5 ,6 ,7 ,8 ,19 ,21 ,22 , 2
16 ,17 ,18 ,19 ,21 ,22 ,23 ,24 ,25 ,26 ,27 23 ,24
24 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,16 ,17 ,20 ,21 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 ,15 , 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 , 2
23 ,24 ,25 ,27 16 ,17 ,18 ,19 ,21 ,22 ,23 ,24 ,25 ,26 ,27 16 ,17 ,21 ,23 ,24 ,25 ,27
25 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,14 ,16 ,17 ,20 ,21 , 1 ,2 ,3 ,4 ,6 ,7 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 , 2 ,3 ,4 ,6 ,7 ,11 ,12 ,14 ,16 ,17 , 6
23 ,24 ,25 ,27 18 ,21 ,22 ,24 ,25 ,26 21 ,24 ,25
26 1 ,2 ,3 ,5 ,6 ,7 ,8 ,15 ,20 ,21 ,22 ,23 ,24 ,25 ,26 1 ,3 ,6 ,10 ,11 ,12 ,15 ,26 1 ,3 ,6 ,15 ,26 7
27 4 ,5 ,6 ,7 ,8 ,19 ,20 ,21 ,22 ,23 ,24 ,27 1 ,2 ,3 ,4 ,6 ,10 ,11 ,12 ,13 ,14 ,15 ,16 ,17 ,18 , 4 ,6 ,24 ,27 5
24 ,25 ,27

2. Dependent variables: These variables have weak drive
power, but relatively higher dependency compared to
other components.
3. Linking variables: These variables possess strong drive
power and strong dependency. They are inherently
unstable, meaning that any action taken regarding
these components can not only directly affect other
components but also have a significant impact on
themselves through feedback from other components.
4. Independent variables: This group comprises variables
with strong drive power but weak dependency. These
are key variables that, when modified, can influence
the other variables significantly.
It is important to note that delineating the boundary
between these four categories is essential. In the MICMAC
method, the border points are typically one unit larger
than the average number of components, meaning that if
there are n components, the border line would be equal
to: 1 þ (n/2).
After constructing the matrix and determining the
boundary lines, the components were arranged based on
their levels of drive power and dependency within the
system.
Results
Steps 1–4
Using the search strategy mentioned in Appendix A
(Supplementary material), a total of 10,135 articles were
extracted from all databases. Finally, 16 studies were
included in the final analysis (Appendix B, Supplementary
material). A total of 147 prerequisites and facilitator factors
(including 22 subcategories and seven categories), as well
 MEDICAL TEACHER 7

Table 4. Level partitioning of the challenges and barriers of lecture-free curriculum in medical education.
No. Reachability set Antecedent set Intersection Set Level
1 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,22 ,23 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,22 ,23 4
15 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,26 ,27
2 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,22 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,22 1
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25
3 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 ,22 1 ,2 ,3 ,4 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 ,22 2
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25
4 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 1
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25
5 1 ,2 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,22 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,22 1
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25
6 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 1
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25
7 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 ,22 ,23 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 1
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 ,22 ,23
8 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 ,19 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 , 1
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25 18 ,19
9 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 1
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25
10 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,17 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,17 1
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ,25
11 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 11 11 8
15 ,16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,25
12 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,12 ,13 ,14 ,16 , 11 ,12 12 7
17 ,18 ,22 ,23 ,25
13 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,13 ,16 ,17 ,18 11 ,12 ,13 13 6
14 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,14 ,16 ,17 ,18 , 11 ,12 ,14 14 6
22 ,23
15 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,15 ,16 ,17 ,18 , 11 ,15 ,19 ,21 15 ,19 ,21 7
19 ,20 ,21 ,22 ,23
16 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 1 ,2 ,3 ,5 ,6 ,7 ,8 ,9 ,11 ,12 ,13 ,14 ,15 , 2 ,3 ,5 ,6 ,7 ,8 ,9 ,16 2
16 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,25
17 2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 1 ,2 ,3 ,5 ,6 ,7 ,8 ,9 ,10 ,11 ,12 ,13 ,14 , 2 ,3 ,5 ,6 ,7 ,8 ,9 ,10 ,17 3
15 ,17 ,18 ,19 ,20 ,21 ,22 ,23 ,25
18 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 ,22 ,23 3 ,6 ,7 ,8 ,9 ,11 ,12 ,13 ,14 ,15 ,18 ,19 , 3 ,6 ,7 ,8 ,9 ,18 ,22 ,23 5
20 ,21 ,22 ,23 ,25
19 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,15 ,16 ,17 ,18 , 11 ,15 ,19 ,20 ,21 15 ,19 ,20 ,21 6
19 ,20 ,21 ,22 ,23
20 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,15 ,16 ,17 ,18 , 11 ,15 ,19 ,20 ,21 15 ,19 ,20 ,21 6
19 ,20 ,21 ,23
21 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,15 ,16 ,17 ,18 , 11 ,15 ,19 ,20 ,21 15 ,19 ,20 ,21 6
19 ,20 ,21 ,22 ,23
22 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 ,22 ,23 1 ,2 ,3 ,5 ,7 ,11 ,12 ,14 ,15 ,18 ,19 ,21 , 1 ,2 ,3 ,5 ,7 ,18 ,22 ,23 4
22 ,23 ,25
23 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 ,22 ,23 1 ,7 ,11 ,12 ,14 ,15 ,18 ,19 ,20 ,21 , 1 ,7 ,18 ,22 ,23 4
22 ,23 ,25
24 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,24 24 24 5
25 1 ,2 ,3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 ,16 ,17 ,18 , 11 ,12 ,25 25 6
22 ,23 ,25

as 101 challenges and barriers (including 15 subcategories
and six categories) to the development of lecture free edu-
cation in preclinical medical courses, were identified. We
combined the results of the interview with the review
phase. In total, 56 participants (including 18 managers, 17
faculty members, and 21 medical students from various
educational levels, including basic science students, physio-
pathology students, internship students, and interns) were
interviewed. The duration of the interviews ranged from 25
to 150 min, with an average of 65 min. By examining the
full text of the interviews and conducting directed content
analysis, a total of 189 prerequisites and facilitators, as well
as 87 challenges and barriers to the development of lec-
ture-free curriculum in the general medical preclinical
course at TUMS, were identified. Based on the previously
formed categories resulting from the text review and con-
tent analysis, these were classified into 26 subcategories
and eight categories of prerequisites and facilitators,
including: capacity building, cultural preparation, support-
seeking, infrastructures, teaching and learning methods,
reflection, assessment, and influential environmental factors,
and 20 subcategories and seven categories of challenges
and barriers, including: inadequate readiness, lack of appro-
priate cultural infrastructure, insufficient support, lack of
necessary infrastructures, teaching and learning challenges,
assessment challenges, and unfavorable environmental fac-
tors (Appendices D and E, Supplementary material).
After completing the matrices by the experts, the fre-
quency index was used to form the final structural self-
interaction matrices (SSIMs) (Appendices H and I,
Supplementary material). In step 3, the symbols in the
SSIMs were converted into 0s and 1s according to the
specified rules, and IRMs were obtained (Appendices J and
K, Supplementary material). After obtaining the IRMs, their
internal consistency was ensured. For example, in the
Appendix J (Supplementary material), row P10, the zeros
indicate that this factor does not directly affect factors P4,
P9, P15, P18, P19, P21, P23, P26, and P27. However, after
investigating transferability, as explained in step 4 in the
methods part, it was determined that P10 indirectly corre-
lates with all these factors. Therefore, in this row and
opposite the mentioned factors, instead of the number 0,
we placed 1. Ultimately, it is observed that P10 has both
direct and indirect effects on all other factors, making it
8 S. KARAMI ET AL.
Figure 1. MICMAC matrix of the prerequisites and facilitators of lecture-free curriculum in medical education.
the most driving factor. This process was also applied to all
other factors until the matrices were adjusted, missing rela-
tionships were replaced with 1, and Final Reachability
Matrices were obtained (Tables 1 and 2).
Step 5: Determination of variable levels and
prioritization
After establishing the sets of reachability, antecedent, and
their intersections for each factor, factors were categorized
into the first level where their reachability and intersection
sets were equal. Accordingly, ‘Enhancing Student
Motivation’ and ‘Adhering to Principles of Teaching and
Learning’ formed the first level of prerequisites and facilita-
tors, having the least influence and the highest depend-
ency. Subsequently, by removing these two factors from all
sets, the reachability and intersection sets of components
7, 21, 23, and 24 became equal, and thus, these factors
were placed in the second level. Regarding the challenges
and barriers, ‘Insufficient Student Preparedness,’
‘Inconsistency of Student Attitudes with lecture-free cur-
riculum,’ ‘Resistance of Faculty,’ ‘Student Resistance,’ ‘Lack
of Faculty Motivation,’ ‘Lack of Student Motivation,’ ‘Faculty
Concerns,’ and ‘Student Concerns’ were placed in the first
level. Then, by removing these factors from all sets, compo-
nents 3 and 16 were placed in the second level. By

Figure 2. MICMAC matrix of the challenges and barriers of lecture-free curriculum in medical education.
repeating this process, the next levels of the models were
also determined, as presented in Tables 3 and 4.
Step 6: Drawing interpretive structural models
Using the identified levels, prerequisites, facilitators, chal-
lenges, and barriers were arranged in two structural models
with 10 levels and eight levels, respectively (Figures 3 and
4). The different levels are determined through a level par-
titioning process using the ISM method, which reveals the
driving and dependence power of a variable and how it
connects with variables at the same level and those in the
level above.
The models comprise vertices, nodes, and edges that
illustrate the connections among variables. The
MEDICAL TEACHER 9
relationships between them were represented by direc-
tional arrows based on the final reachability matrix. For
example, if there is a relationship between factors P10 and
P13, it is depicted by an arrow pointing from P10 to P13.
Step 7: MICMAC analysis
In this study, a borderline was determined for the lec-
ture-free curriculum facilitators and prerequisites based on
27 components with a score of 15, and for the obstacles
and challenges of lecture-free curriculum based on 25
components with a score of 14. Subsequently, after defin-
ing the boundaries of the factors based on their driving
power and dependency in one of the four sections of
10 S. KARAMI ET AL.
Figure 3. ISM model for the prerequisites and facilitators of lecture-free curriculum in medical education.
the matrix, they were categorized accordingly. Figures 1
and 2 represent four quadrants denoting independent,
dependent, linkage, and autonomous classes. For
example, a variable with a driving power of 26 and a
dependency of 11 is situated in a position with an 11
dependency along the x-axis and a driving power of 26
along the y-axis. Based on its spatial location, it can be
defined as an independent factor.
The ‘independent factors’ in the upper left quadrant of
these figures indicate high driving power and low depend-
ency. Independent factors serve as keys to understanding
system behavior, as most other system factors depend on
them. Among the factors placed in this category as prereq-
uisites and facilitators, factor P10 (‘Presenting relevant evi-
dence about the curriculum without lecturing’) has the
highest driving force and independently (without being
influenced by other system factors) is determining the sys-
tem’s state. Hence, it is considered a key factor at the 10th
level of the model.
Factors placed in the dependent cluster have weak driv-
ing power but strong dependency. Consequently, they are
dependent on other factors and require more attention.
Changes in these variables sometimes result from the
impact of independent variables, and occasionally this sus-
ceptibility is, in fact, an indirect effect of the influence of
independent variables (drivers) on linkage variables. In this
study, most challenges and obstacles fall into this category,
indicating that addressing independent and key challenges
and efforts to overcome them will also address a significant
number of identified challenges in this category.

Figure 4. ISM model for the challenges and barriers of lecture-free curriculum in medical education.
The ‘linkage factors’ in the upper right quadrant above
the chart have high driving power and high dependency
simultaneously. The action or impact of driving factors
passes through the ‘linkage’ factors. Therefore, depending
on their value, these factors can either enhance or hinder
the impact of influential factors. In this study, most pre-
requisite and facilitator factors fall into this category.
Both figures show that only two factors are in their
autonomous clusters. Factors placed in the autonomous
cluster have weak driving power and weak dependency.
They are separate from the model but have few powerful
links. In fact, they do not have a significant impact on the
system. The low autonomy of these factors in this study
implies that most identified and studied factors are
MEDICAL TEACHER 11
interconnected, play significant roles, and require stake-
holders’ attention.
Discussion
This research was conducted with the aim of identifying
the prerequisites, facilitators, challenges, and obstacles of
lecture-free curriculum in medical education, establishing
structural interrelationships among these components, and
identifying dominant factors using the ISM technique. As a
result, a set of various variables directly related to the
implementation of lecture-free curriculum were categorized
into two comprehensive hierarchical models, and their
12 S. KARAMI ET AL.
relationships and sequences were determined, enabling
educational managers to initiate necessary changes for the
development of lecture-free curriculum by focusing on the
most effective factors (Sushil 2012).
‘Providing relevant evidence regarding lecture free edu-
cation’ emerged as the most important factor in this
model, followed by ‘allocation of sufficient budget,’
‘awareness of managers,’ ‘effective leadership in lecture
free education,’ ‘university support,’ and ‘existence of a
development committee in the curriculum management
structure’ at two higher levels as other key prerequisites
and facilitators. These factors play a fundamental and vital
role in the problem structure, shaping other strategic and
dependent factors accordingly. Key factors significantly
influence other factors and play a crucial role in the devel-
opment of lecture free curriculum. Therefore, greater atten-
tion should be paid to these key factors.
Since individuals’ beliefs can create significant barriers
to such changes (Graffam 2007), from the experts’ perspec-
tive, before any support is provided, individuals must first
be convinced through the presentation of relevant and
strong evidence (Van Horne and Murniati 2016). This find-
ing can be explained using the elaboration likelihood
model (ELM), proposed by Petty and Cacioppo in the
1980s. ELM suggests that attitudes and beliefs of people
can be changed through two distinct routes: the central
route and the peripheral route. According to ELM, when
individuals have high motivation and the ability to process
information deeply, they are likely to use the central route
of persuasion, meaning they scrutinize the arguments and
evidence presented to them and make decisions based on
the strength of the arguments. The central route is more
effective when the presented arguments are strong, rele-
vant, and valid (Petty and Cacioppo 1986; Li et al. 2021;
Lam et al. 2022). Educators and leaders should prioritize
offering relevant and strong evidence that supports lecture
free curriculum. This evidence can include research find-
ings, case studies, statistical data, and expert opinions.
The designation of ‘Providing relevant evidence’ as the
most crucial factor in the prerequisites model can also be
explained using theory of information processing.
According to this theory, individuals engage in two types
of information processing: automatic processing and con-
trolled processing. Automatic processing is fast, effortless,
and requires minimal cognitive effort. On the other hand,
controlled processing is slower, more effortful, and
demands greater cognitive resources. When individuals
face a decision, they may rely on automatic processing,
which often relies on heuristics or mental shortcuts.
However, if the decision is complex or significant, such as
replacing a lecture-based education with lecture-free cur-
riculum, they may engage in controlled processing and
seek additional information to make a more informed deci-
sion. This is where the need for evidence arises. Individuals
who require evidence for decision-making may be engaged
in controlled processing and seek out additional informa-
tion for informed decision-making. They may exhibit
greater skepticism toward the information presented to
them and may seek additional confirmation before making
a decision (Czyz_ 2021).
Tsang and Harris in their study refer to the possibility of
addressing misconceptions among second-year medical
students regarding lecture-free curriculum by providing
strong and convincing evidence of its benefits.
Furthermore, the study indicates that by creating opportu-
nities for presenting evidence through journal clubs, webi-
nars, and inviting research experts in education to
seminars, potential misinterpretations of medical faculty
about active teaching methods can be corrected (Tsang
and Harris 2016). In general, students and faculty members
who are exposed to persuasive and convincing evidence
supporting these methods are more likely to accept and
show greater inclination toward using these teaching
approaches (Blumberg 2016).
While numerous studies support lecture-free curriculum,
implementing real changes in instructional strategies may
require more than just providing evidence, as innovators
are seldom convinced solely by evidence (Tsang and Harris
2016). Therefore, awareness-raising among managers,
adequate budget allocation, and support and encourage-
ment from university administrators play a crucial role in
promoting and facilitating the adoption of lecture-free cur-
riculum in pre-clinical medical courses. Informed managers,
by establishing policies and providing the necessary resour-
ces and facilities for active teaching, can have a significant
impact on enhancing the quality of education (Allen 2018;
Parmelee et al. 2020; Denaro et al. 2022).
To encourage instructors to prioritize lecture free cur-
riculum, departmental (e.g. faculty members and chairs)
and institutional support (e.g. the faculty, educational vice
chancellor’s office, and management office) are required
for lasting changes to occur (Remington et al. 2015).
Departments and institutions can demonstrate the value of
teaching by rewarding educators for their efforts in stu-
dent-centered learning, experimenting with these
approaches, and adopting them. Additionally, institutions
can support lecture-free curriculum by providing financial
support or offering small incentives or credits for participat-
ing in such programs (Wieman 2015).
Furthermore, the presence of a dedicated committee in
the management structure can aid in providing develop-
ment programs for instructors, creating relevant educa-
tional opportunities, and offering guidance and resources
for effective implementation.
On the other hand, in the model of challenges and
obstacles, ‘insufficient support from the university’ was
identified as the most critical barrier and challenge, posi-
tioned at the lowest level of the ISM model due to its sig-
nificant influence on other factors. Subsequently, ‘lack of
separate budget allocation,’ ‘inadequate physical space,’
‘shortage of necessary resources and equipment,’ ‘lack of
human resources,’ ‘wrong and inconsistent regulations,’
and ‘Inconsistency of the faculty evaluation system, the
comprehensive evaluation system, and some curriculum
components with lecture-free curriculum’ were recognized
as other key challenges and obstacles.
Numerous studies have highlighted the lack of support
as a barrier to institutional changes such as lecture-free
curriculum. Educational transformation requires managers
who understand change management. Institutional change
must be regarded as a process, and educational transform-
ation largely depends on the readiness of faculty, including
their receptivity to new teaching perceptions and motiv-
ation. Managers should provide opportunities to address

gaps in these areas and support the formation of profes-
sional identities. They can also identify faculty advocates
for lecture-free curriculum to guide the educational
changes (McCoy et al. 2018; Heck et al. 2023).
However, a study by Van Horne and Murniati aimed at
examining cultural factors influencing faculty and depart-
ment managers’ decisions regarding active teaching meth-
ods and their integration into curricula, revealed an
observed discrepancy in the university. Despite leadership
support for implementing active methods, only a subset of
faculty members utilizes them. The existence of other chal-
lenges and obstacles such as inadequate physical space,
limited time for changing teaching strategies, and student
resistance were cited as reasons for this inconsistency (Van
Horne and Murniati 2016).
Limited financial and physical resources can also be a
barrier to the implementation of lecture-free curriculum. To
execute this form of education, there might be a need for
specialized training, equipped spaces, advanced technolo-
gies, and diverse educational resources, which require
expenses and investments (Jahan et al. 2016; _Ilhan 2022).
To support effective change, healthcare program adminis-
trators should allocate sufficient time and budget for fac-
ulty to develop their knowledge, skills, and instructional
materials for active learning (Aksit et al. 2016; Allen 2018).
Based on Nordquist’s studies, many healthcare profes-
sional education programs worldwide are currently being
conducted in spaces that can be described as monologue-
centered educational environments. Such spaces are
designed solely for information transmission. However,
twenty-first-century curricula focus on active learning
teaching methods and require the creation of appropriate
physical spaces. These spaces can provide a suitable plat-
form for interactive learning, group work, and experiential
interactions within the educational environment (Nordquist
and Laing 2014, 2015; Nordquist et al. 2016).
Many instructors believe that teaching large classes in
large lecture-style rooms with fixed seating (e.g. theater-
style auditoriums) makes it challenging to foster student
engagement and employ student-centered techniques.
Classrooms with movable chairs, tables, or whiteboards
provide an environment conducive to enhancing student-
to-student and student-to-instructor interactions (Stains
et al. 2015). Similarly, in Shweiki et al.’s study, faculty mem-
bers mentioned room arrangement as a barrier to active
learning during resident conferences (Sawatsky et al. 2015).
In line with this, Alhawiti examined the impact of active
learning on students’ competencies and skills in a medical
school. The results demonstrated that implementing active
learning teaching methods can increase student participa-
tion and engagement in the learning process, leading to
improvements in their technical and specialized skills.
However, challenges and obstacles to adopting these
methods may exist, including limited access to suitable
equipment and spaces, structural and organizational con-
straints, financial constraints, and instructors’ readiness and
proficiency in active learning teaching methods (Alhawiti
2023).
The lack of attention from policymakers and administra-
tors toward lecture-free curriculum, as well as incompatible
regulations, may create constraints and obstacles for both
instructors and students, hindering the development and
MEDICAL TEACHER 13
effective implementation of active learning teaching meth-
ods in medical education (Alhawiti 2023). A relevant theory
that can explain our findings is the expectancy theory,
which suggests that individuals are motivated when they
believe their efforts will lead to desired outcomes. In the
context of education, this means that instructors are more
motivated and engaged when they believe their efforts will
yield positive results for their students. For example, if
instructors are obligated to adhere to rules and methods
that they perceive as ineffective or counterproductive, they
may have less motivation and be less involved in teaching.
However, if they are given the opportunity to participate in
decision-making processes and have a say in the rules and
methods governing their teaching, they may have higher
motivation and engagement (Vroom 1964; Shweiki et al.
2015). Involving individuals in the decision-making process
and seeking their input can foster a sense of ownership
and reduce resistance to change. Educators and leaders
can organize workshops, focus groups, or collaborative dis-
cussions where individuals can express their concerns and
contribute to the development of the change initiatives.
This participatory approach can help individuals feel heard
and valued, increasing their receptiveness to the evidence
presented.
Alignment between promotion policies, teaching meth-
ods, and active teaching approaches can create a support-
ive environment for instructors, increase their motivation to
utilize these methods, and ultimately facilitate their profes-
sional development. Improving the faculty evaluation sys-
tem to incentivize the use of active teaching methods
should also be considered. Having criteria in the faculty
evaluation system that measure the impact of these meth-
ods on students’ skill development can be effective
(Alhawiti 2023). A study by Limeri et al. explored how the
department or institution’s evaluation of instructors’ teach-
ing performance influences their instructional approaches
and professional decisions. For example, departments and
institutions may request instructors to use student-centered
teaching methods as part of the evaluation and promotion
system. If structures for evaluating and rewarding this type
of teaching are absent, instructors may be less influenced
by such practices. The results of this study indicate that the
stronger the impact of performance evaluation on promo-
tion decisions, the higher the likelihood of adopting stu-
dent-centered approaches (Limeri et al. 2020).
However, when the use of lecture-free curriculum
approaches is required and part of annual performance
reviews, even instructors with some resistance may make
changes to their teaching methods (Blumberg 2016). On
the other hand, instructors often receive lower grades from
students’ evaluations when transitioning to active learning.
Therefore, this aspect should also be considered in annual
evaluations (Tsang and Harris 2016).
Furthermore, restructuring the education of a large
course requires simultaneous changes in course objectives,
teaching strategies, and assessments (Parmelee et al. 2020).
At Iowa State University (ISU), a Faculty Learning
Community (FLC) is utilized to develop active learning
methods, where instructors collaborate as a teaching team.
As part of the FLC work, faculty members dedicate time to
discuss effective assessment, its alignment with learning
objectives, active teaching methods, and reflecting on
14 S. KARAMI ET AL.
students’ successes and challenges during the instruction
process (Elliott et al. 2016).
Many of the key challenges discussed above exist as
strategic prerequisites and facilitators at the intermediate
levels of the prerequisites and facilitators model. These fac-
tors play a lesser role than the primary key factors, but
they are still of significant importance and can contribute
to the successful implementation of strategies for improv-
ing lecture-free curriculum. Therefore, in addition to the
aforementioned factors, elements such as ‘the existence of
an information dissemination system,’ ‘experience sharing,’
and ‘cultural preparation’ are strategic prerequisites and
facilitators, respectively, in terms of power of influence.
Access to up-to-date educational resources through an
active information dissemination system can keep students
informed and lead to more meaningful and practical learn-
ing experiences. Effective and up-to-date communication
with students and faculty members can facilitate the shar-
ing of experiences and successful skills in lecture free edu-
cation, fostering greater engagement and collaboration in
the teaching and learning process, thus accelerating stu-
dents’ learning, and positively influencing the quality of
medical preclinical education (Elliott et al. 2016; Dhawan
2018).
Faculty members who have experienced the use of
active teaching methods and achieved successful results
may encourage their colleagues to adopt these methods
during such sessions (_Ilhan 2022). Based on Denaro’s study,
professors who receive validation and encouragement from
their peers are more likely to use these methods (Denaro
et al. 2022). As observed, cultural preparation is placed at
level 5 of the model and holds a greater dependence com-
pared to other strategic factors at lower levels. It can be
argued that, with the presence of the prerequisites and
facilitators mentioned so far, an appropriate culture will
gradually form within the organization concerning the
implementation of lecture-free curriculum, which, in turn,
will facilitate the establishment of other factors at higher
levels (_Ilhan 2022).
On the other hand, at the intermediate levels of the chal-
lenges and obstacles model such as ‘weak interdisciplinary
coordination,’ ‘increased workload for professors and stu-
dents,’ and ‘difficulty in time management’ have been identi-
fied as strategic challenges that can significantly impact the
development of lecture-free curriculum in universities. In the
study by Parmelee et al., it was stated that during the imple-
mentation of lecture-free curriculum at Boonshoft School of
Medicine at Wright State University, to establish interdiscip-
linary coordination, professors from basic and clinical scien-
ces often convened in planning sessions for each new course
to review and revise all the materials used for students’ pre-
class preparation and in-class activities. Hundreds of MCQs
(multiple choice questions) and learning activities were writ-
ten, reviewed, and edited by these interdisciplinary groups
(Parmelee et al. 2020).
Several studies have highlighted the increased workload
and time constraints associated with implementing lecture-
free curriculum from the perspectives of both students and
professors (Sawatsky et al. 2015; Alhawiti 2023; Heck et al.
2023). Jahan et al. found that lack of sufficient time in class,
the comfort level with traditional lectures, and insufficient
time for preparing instructional materials were perceived as
the main obstacles by educators (Jahan et al. 2016).
At the highest levels of both models, dependent factors
have been identified as receiving the most significant
impact. These dependent factors are more responsive to
policies, decisions, and the performance of key and stra-
tegic actors and do not play a fundamental role in prob-
lem-solving. For example, enhancing the motivation of
students and faculty members. It can be inferred that
when individuals are provided with credible evidence, a
separate budget is allocated for their activities, any relevant
support is provided by the university administration and
the institution as a whole, participation in effective devel-
opment courses is facilitated, suitable physical space and
necessary equipment are made available, educational regu-
lations, promotion and tenure systems, assessment meth-
ods for learners, and other curriculum components are
aligned, sessions are held to share effective experiences
and ideas, necessary human resources are provided, a suit-
able culture is formed within the institution, and, overall,
the university values system revolves around this issue, the
necessary motivation for the implementation of lecture-free
curriculum will be fostered in both faculty and students
(Sawatsky et al. 2015; Park et al. 2021; Heck et al. 2023).
Regarding the model of challenges and barriers, if
effective measures are taken to address the key and stra-
tegic challenges and obstacles, the dependent challenges
and barriers will subsequently be influenced. For example,
by resolving the challenges and obstacles discussed in
detail, the resistance and concerns of faculty and students
will gradually diminish. Their attitudes will align with lec-
ture free curriculum, and they will gain the necessary
motivation, leading to increased preparedness in the class-
rooms (Allen 2018; Alhawiti 2023).
Conclusions
In conclusion, this research identified the prerequisites,
facilitators, challenges, and barriers of lecture-free curricu-
lum and examined the interrelationships between these
components using the ISM technique, highlighting their
significant importance. Therefore, educational managers
and policymakers can utilize the findings of this study to
implement necessary changes in the design and implemen-
tation of lecture free education, leading to more effective
improvements in the quality and success of education. This
research also demonstrates that emphasizing strong evi-
dence and information can bring about more impactful
changes in lecture-free curriculum programs and leverage
effective attitudes and beliefs to enhance teaching and
learning. With this approach, the main objective of this
research, which is to enhance lecture free education in
general medical courses, will be achieved to a much
greater extent.
Limitations and suggestions for future studies
One limitation of this study is related to the inherent con-
straints of the ISM technique, which relies on expert judg-
ments. The management of such a large number of
variables further complicates ISM interpretation.
 MEDICAL TEACHER 15

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