Comparison of Peyton's Four-Step Approach and Halsted's 'See One, Do One' Method for Teaching Basic Surgical Skills

Comparison of Peyton's Four-Step Approach and Halsted's 'See One, Do One' Method for Teaching Basic Surgical Skills: A Randomised Study Assessing Long-Term Retention in a Pakistani Medical School

This study aimed to compare Halsted's "See One, Do One" method with Peyton's Four-Step Approach for teaching basic surgical skills to undergraduate medical students in a simulated skills-laboratory setting at Department of Surgery, Dow University of Health Sciences & Dr. Ruth K. M. Pfau Civil Hospital Karachi. Medical students were randomised to Halsted and Peyton Arms and were taught Four Surgical Skills i-e Gloving by open method, Incision Making, Interrupted suturing, One-handed reef knot. After three months, all participants were recalled to perform the same set of skills. Each participant performed individually in a controlled setting while being video recorded. The recordings were later evaluated by an independent assessor(academic surgeon) blinded to the participants' group allocation.

Skill performance was assessed using a six-point Likert scale, where 1 = unsatisfactory, 2 = satisfactory with mistakes, 3 = satisfactory, 4 = average, 5 = good, and 6 = perfect.

Study Overview

• Status: Completed
• Conditions: Retention of Basic Surgical Skills; Surgical Skills Performance Score
• Intervention / Treatment: Behavioral: Halsted's approach; Behavioral: Peyton's approach

Detailed Description

Skills-lab training as a procedural teaching approach is nowadays part of the training programs of almost all medical faculties. Certain components like observation, clinical skills, practice and decision-making have been shown to contribute to a successful learning experience in skills labs. It offers a safe, "mistake-forgiving" training environment that allows students to practice procedures on mannequins, with standardised patients or with each other before performing procedural skills on real patients,

The positive effect of skills-lab training sessions on learning outcomes and transfer of acquired skills to clinical practice has been shown in a variety of different settings. It has become a necessity for every undergraduate medical student/teacher to be aware of the basic methodologies taught through skills lab training, which should be practised in every medical institution.

In the studies, a lot of instructional techniques that include various steps to convey clinical technical skills to learners have been described. It includes some established teaching techniques, for example, Halsted's traditional teacher-centred "See one do one" approach. In this form of teaching, students learn only by observing an experienced surgeon explaining and demonstrating the skill. This can later be practised on artificial skin models. It's a process of active learning in a continual cycle. Another instructional approach that is becoming increasingly pervasive in medical studies is "Peyton's Four-Step Approach" This methodology was established based on the work of Peyton and was readily adapted in the last decade by medical institutes throughout the world.

It consists of four clearly defined instructional steps:

• Step 1 - "Demonstrate": The trainer demonstrates the skill without adding any comments.
• Step 2 - "Talk the trainee through": The trainer demon¬strates the respective skill while explaining each proce¬dural sub step in detail.
• Step 3 - "Trainee talks trainer through": The trainer performs the skill for a third time, based on the sub steps described to him/her by the trainee.
• Step 4 - "Trainee does": The trainee performs the skill on his/her own

Probable benefits of the technique include the grouping of several learning theories. Especially step three, when the trainee instructs the trainer, seems to be an important step in student learning. The student first has to analyse the first two steps, which are based on a social-cognitive approach to learning theory, i.e. thinking and sharing. This gives the student time to organise their thoughts before actively saying it. In addition, the reasoning process called self-explanation seems to facilitate the integration of new knowledge into existing knowledge.

We know it is no question that the instructional methods used to develop better grip of new clinical skills have huge impact in developing skill performance, but the contrasting results of different instructional methods for different surgical skills including both basic and advance surgical skills, require further evaluation.

This study aims to determine the better approach of teaching surgical skills, so that the same would be employed in future to impart surgical skills to junior surgeons, postgraduate trainees, interns and undergraduate students in skills lab.

• Study Type: Interventional
• Enrollment (Actual): 50
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Pakistan
  • Sindh
    • Karachi, Sindh, Pakistan, 74200
      • Dow University of Health Sciences & Dr. Ruth K. M. Pfau Civil Hospital Karachi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Medical students of DMC with no prior exposure to surgical skills.

Exclusion Criteria:

• Students who had previously attended any basic surgical skills workshop.
• Students who had participated in surgical camps or had prior hands-on surgical experience.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Halsted; Skills taught using Halsted's 'See one, do one' approach	Behavioral: Halsted's approach; Participants in Halsted group were taught the following four skills employing Halsted 'see one do one' approach: Gloving by open method.; Incision Making; Interrupted suturing; One-handed reef knot
Experimental: Peyton; Skills taught using Peyton's Four-Step Approach	Behavioral: Peyton's approach; Participants in this group were taught the following four skills employing Peyton's Four-step approach: Gloving by open method.; Incision Making; Interrupted suturing; One-handed reef knot

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Skill Performance score	After three months, all participants in both arms were recalled to perform the same set of skills. Each participant performed individually in a controlled setting while being video recorded. The recordings were later evaluated by independent assesor blinded to the participants' group allocation. Skill performance was assessed using a six-point Likert scale, where 1 = unsatisfactory, 2 = satisfactory with mistakes, 3 = satisfactory, 4 = average, 5 = good, and 6 = perfect.	3 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to Teach skill	The time required to teach each of the four skills was recorded in both arms.	1 day

Collaborators and Investigators

• Sponsor: Dow University of Health Sciences
• Investigators: Principal Investigator: Syed Ali Haider, FCPS,F.MAS, FACS, Dow University of Health Sciences & Dr. Ruth K. M. Pfau Civil Hospital Karachi

Publications and helpful links

General Publications

• Romero P, Gunther P, Kowalewski KF, Friedrich M, Schmidt MW, Trent SM, De La Garza JR, Muller-Stich BP, Nickel F. Halsted's "See One, Do One, and Teach One" versus Peyton's Four-Step Approach: A Randomized Trial for Training of Laparoscopic Suturing and Knot Tying. J Surg Educ. 2018 Mar-Apr;75(2):510-515. doi: 10.1016/j.jsurg.2017.07.025. Epub 2017 Aug 8.
• Seifert LB, Schnurr B, Stefanescu MC, Sader R, Ruesseler M, Sterz J. Comparing video-based versions of Halsted's 'see one, do one' and Peyton's '4-step approach' for teaching surgical skills: a randomized controlled trial. BMC Med Educ. 2020 Jun 17;20(1):194. doi: 10.1186/s12909-020-02105-5.
• Krautter M, Weyrich P, Schultz JH, Buss SJ, Maatouk I, Junger J, Nikendei C. Effects of Peyton's four-step approach on objective performance measures in technical skills training: a controlled trial. Teach Learn Med. 2011 Jul-Sep;23(3):244-50. doi: 10.1080/10401334.2011.586917.
• Giacomino K, Caliesch R, Sattelmayer KM. The effectiveness of the Peyton's 4-step teaching approach on skill acquisition of procedures in health professions education: A systematic review and meta-analysis with integrated meta-regression. PeerJ. 2020 Oct 9;8:e10129. doi: 10.7717/peerj.10129. eCollection 2020.
• Kotsis SV, Chung KC. Application of the "see one, do one, teach one" concept in surgical training. Plast Reconstr Surg. 2013 May;131(5):1194-1201. doi: 10.1097/PRS.0b013e318287a0b3.

Study record dates

Study Major Dates

• Study Start (Actual): January 9, 2025
• Primary Completion (Actual): March 23, 2026
• Study Completion (Actual): March 23, 2026

Study Registration Dates

• First Submitted: July 24, 2026
• First Submitted That Met QC Criteria: July 24, 2026
• First Posted (Actual): July 29, 2026

Study Record Updates

• Last Update Posted (Actual): August 10, 2026
• Last Update Submitted That Met QC Criteria: August 6, 2026
• Last Verified: August 1, 2026

More Information

Terms related to this study

• Keywords: Surgical skills; peyton's method; Halsted's Method
• Other Study ID Numbers: IRB-1784/DUHS

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: All of the individual participant data collected during the trial, after deidentification.
• IPD Sharing Time Frame: Beginning 3 months and ending 5 years following article publication.
• IPD Sharing Access Criteria: Researchers who provide a methodologically sound proposal.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No