Comparison of Peyton's Four-Step Approach With the Conventional Bedside Technique in Teaching Clinical Examination Skills to Medical Students.

BACKGROUND:  Conventional bedside teaching (CBT) is an integral and classical method for imparting clinical skills to undergraduates in medical schools. It is a traditionally successful approach, especially when it comes to imparting patient-doctor relationship skills and knowledge on clinical management. Peyton's four-step approach (PFSA) is one of the newer structured instructional approaches for teaching-learning, especially for imparting procedural and complex psychomotor skills. The present study compares the application of PFSA in teaching complex systemic examination skills to the CBT technique in teaching the same skill to MBBS students. The impact of the acquisition of this examination skill was assessed statistically to compare PFSA and CBT methodologies. METHODOLOGY:  The target population was MBBS (Bachelor of Medicine and Bachelor of Surgery) students; for this study, the phase II MBBS students were considered as the study population since they were relatively naïve to clinical bedside examination skills. Students were allotted groups and they were taught clinical skills through CBT and PFSA separately. Using the OpenEpi toolkit Version 3 open-source sample size calculator for comparing two means, the sample size was 30 students in each group. The students were assessed for their competency and were also made to fill out a feedback questionnaire to compare the two methods of education dispensing.  Results: The results of this study showed that PFSA is definitely suitable for teaching clinical examination skills. The acquisition of skills was found non-inferior to CBT while the retention of these skills was found to be equally good or even superior with PFSA than with CBT.  Conclusion: PFSA has already been proven to be a good teaching method for the acquisition of complex procedural skills. This study expands the role of PFSA in teaching clinical bedside examination skills to medical students. Further large-scale studies may clarify the learning impact and outcomes of PFSA in clinical bedside teaching.

Effectiveness of endotracheal intubation and mask ventilation procedural skills training on second-year student using modified Peyton's Four-Step approach during COVID-19 pandemic.

BACKGROUND: Airway emergency is the reason behind competency in mask ventilation and intubation skills for doctors. Procedural skills are taught through face-to-face training. However, the COVID-19 pandemic has had an impact on the education system, including medical education. The face-to-face training method cannot be carried out and requires a modification to an online method. Therefore, Peyton's Four-Step Approach is modified to adapt this change. OBJECTIVE: Assessing the effectiveness of learning methods between modified Peyton's Four-Step approach and classic Peyton's Four Step approach in learning basic skills of mask ventilation and intubation during the COVID-19 pandemic. METHOD: This was an experimental study with two groups of subjects in the Basic ClinicalSkills module of endotracheal intubation and mask ventilation at the Faculty ofMedicine, Universitas Indonesia during February-June 2022. The first group received training with classic Peyton's Four-Step approach and another group with modified Peyton's Four-Step approach. Both groups were tested and assessed using rubric score and global rating score, and asked to fill a feedback questionnaire. RESULTS: This study was conducted with 133 students in the classic group and 96 students in the modified group. The median rubric score was 21.2 for both groups and the global rating score showed 82%and 78% students passed, for classic and modified group respectively. Therubric score and global rating score, also the pass rate between two learningmethods showed no significant results (P > 0.05). The satisfaction and self-confidence questionnaires got answers 'agree and strongly agree' for all questions. CONCLUSION: The learning method using modified and classic Peyton Four-StepApproach were equally effective for learning basic skill of endotracheal intubation and mask ventilation for students of the Faculty of Medicine,University of Indonesia. Both methods provided equal students' satisfaction and self-confidence.

Stepwise approach to skills teaching in resuscitation: A systematic review.

Aim: To compare the effectiveness of Peyton's four-step approach for teaching resuscitation skills with alternative approaches. Methods: For this systematic review, we followed the PICOST format (population, intervention, comparison, outcome, study design, timeframe) using Peyton's four-step approach as the standard. We included all studies analyzing skills training related to resuscitation and First Aid in any educational setting. Eligible were randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, published conference abstracts, and case series where n ≥ 5). We excluded unpublished results (e.g. trial protocols), commentaries, editorials, reviews. Medline, Embase, PsycINFO, ERIC, CINAHL, and Cochrane were searched from inception until November 10, 2020 (updated November 25, 2022) for publications in all languages as long as there was an English abstract. Titles and abstracts of the papers retrieved were screened, and eligible publications were analysed in full text. From the final set of papers, data were extracted into a spreadsheet, subsequently risk of bias assessment was performed (using RoB2 and ROBINS-I), and the certainty of evidence (using GRADE) for each paper was assessed. Screening of studies, data extraction, risk-of-bias assessment, and assessment of certainty of evidence were all performed by two independent researchers. This review was conducted in adherence with PRISMA standards and was registered with PROSPERO (CRD42023377398). Results: Overall, the search identified 2,574 studies from which 17 were included in the final analysis (14 RCTs, and 3 non-RCTs). The studies involved a total of 2,906 participants from various populations (from lay persons to health care professionals) and analysed nine different resuscitation skills being taught (ranging from chest compressions to needle cricotomy). The alternative teaching approaches ranged from two-steps to five-steps with various modifications of single steps. High methodological and clinical heterogeneity precluded a meta-analysis from being conducted. The risk of bias assessment showed considerable variation between the studies ranging from 'low' to 'serious'. Across all studies, certainty of evidence was rated as very low due to imprecision and inconsistency. Overall, 14 out of 17 studies showed no difference in skill acquisition or retention when comparing Peyton's four steps to other stepwise approaches. Conclusions: Very low certainty evidence suggest that Peyton's four-step approach was not more effective in resuscitation skills training compared to alternative approaches. Funding: None.

Prenatal diagnosis and postnatal verification in fetuses with total anomalous pulmonary venous connection.

Objective: To systematically verify the accuracy of a four-step prenatal ultrasonography in diagnosing fetal total anomalous pulmonary venous connection (TAPVC). Methods: A total of 62 TAPVC fetuses received prenatal ultrasonography and were confirmed by postnatal echocardiography, surgery, or postabortion autopsy. The suspected TAPVC fetuses were further screened by a four-step prenatal ultrasonography for TAPVC classification, pulmonary venous obstruction, and the associated malformations, and followed postpartum. The sonographic features, clinical data, and prognosis of the TAPVC fetuses were retrospectively analyzed. Results: Of the 62 TAPVC fetuses, supracardiac TAPVC was found in 20 cases, intracardiac TAPVC in 12, infracardiac TAPVC in 21, and mixed TAPVC in 9. A total of 30 cases with right atrium isomerism were correctly diagnosed. Of the 11 cases with other intracardiac and extracardiac malformations, 1 case was missed to be diagnosed. Of the 21 isolated TAPVC cases, 6 were missed prenatally and 1 case was prenatally diagnosed as intracardiac and postnatally proved to be mixed (intracardiac type + supracardiac type) by echocardiography. Of the 13 TAPVC live births, 4 infants died in the neonatal period without operation. Of the nine infants undergoing the operation, five recuperated and survived; one survived but had complications with superior vena cava obstruction and collateral circulation formation, and three died postoperatively. Conclusion: The four-step prenatal ultrasound procedure can comprehensively and systematically evaluate fetal TAPVC, detailing the classification, potential obstruction, and associated malformations. It provides substantial support for subsequent prenatal counseling and neonatal assessment. The retrospective analysis also reveals that isolated TAPVC is more prone to be missed in diagnosis.

Teaching fiberoptic-assisted tracheoscopy in very low birth weight infants: A randomized controlled simulator study.

Objective: We developed a fiberoptic-assisted tracheoscopy (FAST) method to avoid direct laryngoscopy during surfactant replacement therapy and compared two training approaches on a very low birth weight (VLBW) infant simulator. Design: This prospective randomized controlled study was conducted at the Department of Neonatology and Pediatric Intensive Care Medicine of the University Medical Center Hamburg-Eppendorf, Germany. Participants: We recruited physicians, trainees, students, and nurses without prior experience in endoscopic techniques. Interventions: Participants were assigned randomly to a group that received instructions according to Peyton's Four-Step Approach and a control group that received standard bedside teaching only. Main outcome measures: Primary endpoints were the total and the component times required to place the bronchoscope and the method success. Results: We recruited 186 participants. Compared with the control group, the Peyton group had a lower mean (±standard deviation) FAST completion time (33.2 ± 27.5 s vs. 79.5 ± 47.9 s, p < 0.001; d = 1.12) and a higher FAST success rate (95% vs. 84%, p = 0.036, V = 0.18). Conclusion: After standardized training, the vast majority of novices completed FAST successfully. Peyton's four-step approach resulted in faster and more successful performance than standardized training.

Structured work-based learning in undergraduate clinical radiology immersion experience.

BACKGROUND: Practical courses in undergraduate medical training often lack a didactic concept. Active participation and learning success largely depend on chance. This study was initiated to evaluate a novel concept of structured work-based learning (WBL) in the course of students' half-day radiology immersion experience (IE). METHODS: This prospective, single-centre cohort study included 228 third-year students of the 2019 summer semester who underwent the obligatory radiology IE at a university hospital. The course was based on a novel structured WBL concept that applied established didactic concepts including blended learning, the FAIR principles of feedback, activity, individualization, and relevance, and Peyton's four-step approach. Outcomes of equal weight were student and supervisor satisfaction with the clinical radiology IE assessed by paper-based- and online survey, respectively. Secondary outcome was achievement of intended learning outcomes assessed by means of mini clinical evaluation exercises and personal interviews. RESULTS: Satisfaction with structured WBL was high in 99.0% of students. Students' expectations were exceeded, and they felt taken seriously at the professional level. Dissatisfaction was reasoned with quality of learning videos (0.6%), little support by supervisors (0.5%), or inadequate feedback (0.6%). Supervising resident physicians rated achievement of intended learning outcomes regarding cognitive and psychomotor competences as excellent for all students. Personal interviews revealed achievement of affective competence in some students. Twelve of 16 (75.0%) supervising physicians were satisfied with focussing on intended learning outcomes and student preparation for IE. Two of 15 (13.3%) supervisors were unsatisfied with time spent, and 4 of 16 (25%) with the approach of assessment. CONCLUSIONS: This study demonstrated that both students and supervisors were satisfied with the novel concept of structured WBL within the scope of clinical radiology IE. Achievement of intended learning outcomes was promising.

[Practical skills training : How suitable is Peyton's four-step approach for residents in urology?] / Vermittlung praktischer Fertigkeiten : Wie geeignet ist Peytons Vier-Schritte-Ansatz für urologische WeiterbildungsassistentInnen?

INTRODUCTION: The aim of residency is to acquire medical skills and abilities. One didactic model is "Peyton's four-step approach". The aim of the present study was to develop and evaluate a modified Peytonian approach for group interactions. The aim was to develop a course for the acquisition of practical skills and training assistants in suture techniques for urology. METHODS: A prospective study was conducted with a total of 38 participants and 6 tutors. In a modified four-step Peytonian approach, various suturing and knotting techniques were taught in a structured manner. Tutors evaluated the procedural activity using observation sheets. In addition, the learning method was evaluated by the participants and the tutors at the end of the course. In order to check the long-term learning success, a renewed survey of the participants was conducted after 6 months. RESULTS: 80% of the participants rated the modified teaching method as useful and 83% of the tutors rated the procedural implementation as good. Fluid movement sequences were difficult independent of the technique taught. After 6 months, the participants significantly improved their procedural skills in all techniques that were taught. CONCLUSION: This paper defines a four-step Peyton-based approach to teaching practical skills such as suturing and knotting used in urological training. The modified teaching method improved practical skills used in urology. This method should be considered in continuing education to promote self-confidence and increase the competence in surgical skills.

Tips for teaching procedural skills.

The teaching of procedural skills required for clinical practice remains an ongoing challenge in healthcare education. Health professionals must be competent to perform a wide range of clinical skills, and are also regularly required to teach these clinical skills to their peers, junior staff, and students. Teaching of procedural skills through the use of frameworks, observation and provision of feedback, with opportunities for repeated practice assists in the learners' acquisition and retention of skills. With a focus on the teaching of non-complex skills, this paper explores how skills are learned; ways to improve skill performance; determining competency; and the provision of effective feedback.

Characterisation of black skin stratum corneum by digital macroscopic images analysis.

Black skin medical images generally show very low contrast. Being in a global initiative of characterisation of black skin horny layer (stratum corneum) by digital images analysis, the authors in this study proposed a four-step approach. The first step consists of differentiation between probable healthy skin regions and those affected. For that, they used an automatic classification system based on multilayer perceptron artificial neural networks. The network has been trained with texture and colour features. Best features selection and network architecture definition were done using sequential network construction algorithm-based method. After classification, selected regions undergo a colour transformation, in order to increase the contrast with the lesion region. Thirdly, created colour information serves as the basis for a modified fuzzy c-mean clustering algorithm to perform segmentation. The proposed method, named neural network-based fuzzy clustering, was applied to many black skin lesion images and they obtained segmentation rates up to 94.67%. The last stage consists in calculating characteristics. Eight parameters are concerned: uniformity, standard deviation, skewness, kurtosis, smoothness, entropy, and average pixel values calculated for red and blue colour channels. All developed methods were tested with a database of 600 images and obtained results were discussed and compared with similar works.

Implementation of the modified four-step approach method for teaching echocardiography using the FATE protocol-A pilot study.

INTRODUCTION: Peyton's four-step approach is well-known and commonly used in medical education. It is a practical and useful method which is simple to apply. The study presents the implementation of the modified four-step approach method to teach how to perform the emergency echocardiographic assessment according to FATE (Focus-Assessed Transthoracic Echo) protocol. The aim of the study was to determine the feasibility and utility of this method FATE protocol teaching. DESIGN: We collected students' feedback relating to perception of this way of teaching. Based on a semistructured interview conducted with the students, as well as an evaluation of the electronic survey, it has been demonstrated that the four-step method is useful for teaching emergency echocardiographic assessment. SETTING: One Polish medical school. PARTICIPANTS: The classes were run in small groups as part of an elective ultrasound course for the fourth- and fifth-year students of the Faculty of Medicine of the Medical College. Twenty-two students were trained. RESULTS: Based on the opinions of the participants of the elective course and the teacher conducting the classes, which involved the use of the modified Peyton's four-step method in teaching echocardiography in emergency cases according to the FATE protocol, it has been determined that the four-step method is effective in imaging training. All participants claim that this method is clear and understandable. Advantages of the methodological approach: a slow-motion demonstration by the instructor, accompanied by the commentary on the activities undertaken and practical exercises performed by the participants, learning through repetition, requirement of constant concentration. CONCLUSIONS: Peyton's approach allows to use of the class time in maximal extend by consolidating new information and facilitating memorization through adequate instructor guidance and observation of the training of the peer students and repetition of the skills acquired.

Peyton's four-step approach for teaching complex spinal manipulation techniques - a prospective randomized trial.

BACKGROUND: The objectives of this prospective randomized trial were to assess the impact of Peyton's four-step approach on the acquisition of complex psychomotor skills and to examine the influence of gender on learning outcomes. METHODS: We randomly assigned 95 third to fifth year medical students to an intervention group which received instructions according to Peyton (PG) or a control group, which received conventional teaching (CG). Both groups attended four sessions on the principles of manual therapy and specific manipulative and diagnostic techniques for the spine. We assessed differences in theoretical knowledge (multiple choice (MC) exam) and practical skills (Objective Structured Practical Examination (OSPE)) with respect to type of intervention and gender. Participants took a second OSPE 6 months after completion of the course. RESULTS: There were no differences between groups with respect to the MC exam. Students in the PG group scored significantly higher in the OSPE. Gender had no additional impact. Results of the second OSPE showed a significant decline in competency regardless of gender and type of intervention. CONCLUSIONS: Peyton's approach is superior to standard instruction for teaching complex spinal manipulation skills regardless of gender. Skills retention was equally low for both techniques.

Peyton's four-step approach: differential effects of single instructional steps on procedural and memory performance - a clarification study.

BACKGROUND: Although Peyton's four-step approach is a widely used method for skills-lab training in undergraduate medical education and has been shown to be more effective than standard instruction, it is unclear whether its superiority can be attributed to a specific single step. PURPOSE: We conducted a randomized controlled trial to investigate the differential learning outcomes of the separate steps of Peyton's four-step approach. METHODS: Volunteer medical students were randomly assigned to four different groups. Step-1 group received Peyton's Step 1, Step-2 group received Peyton's Steps 1 and 2, Step-3 group received Peyton's Steps 1, 2, and 3, and Step-3mod group received Peyton's Steps 1 and 2, followed by a repetition of Step 2. Following the training, the first independent performance of a central venous catheter (CVC) insertion using a manikin was video-recorded and scored by independent video assessors using binary checklists. The day after the training, memory performance during delayed recall was assessed with an incidental free recall test. RESULTS: A total of 97 participants agreed to participate in the trial. There were no statistically significant group differences with regard to age, sex, completed education in a medical profession, completed medical clerkships, preliminary memory tests, or self-efficacy ratings. Regarding checklist ratings, Step-2 group showed a superior first independent performance of CVC placement compared to Step-1 group (P<0.001), and Step-3 group showed a superior performance to Step-2 group (P<0.009), while Step-2 group and Step-3mod group did not differ (P=0.055). The findings were similar in the incidental free recall test. CONCLUSION: Our study identified Peyton's Step 3 as being the most crucial part within Peyton's four-step approach, contributing significantly more to learning success than the previous steps and reaching beyond the benefit of a mere repetition of skills demonstration.