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May 2018 SEA-Q


While teaching intubations to a small group of medical students in the simulation lab, the instructor performs each step required for intubation while providing an explanation of each component needed for this skill. In Peyton’s four-step approach to teaching skills, which step is the instructor using to teach the learners?

  • Demonstration
  • Deconstruction
  • Comprehension
  • Execution/Performance




Learning a procedural skill requires an integration of knowledge and manual dexterity. Without focused instruction, a learner may miss key elements needed for successful acquisition of the skill. In Peyton’s four-step approach to teaching skills, the teacher first demonstrates a skill without explanation, Demonstration. In the second step, Deconstruction, the teacher demonstrates a skill slowly while providing an explanation to each component of the skill. Comprehension is the third step in which the learner describes the components of the skill while the teacher performs the skill. The fourth step is Execution/Performance when the learner finally performs the skill.
Traditionally, the teacher uses these four steps in order to teach one student. A suggested modification of Peyton’s four-step approach allows using the four steps in a small group setting. In this modification, the teacher performs Demonstration and Deconstruction in the standard manner. In the Comprehension step, the first learner describes the skill while the teacher performs the skill. The second learner in the group then describes the skill while the first learner performs the skill (Execution step), and this progression continues through all learners in the group. This modification allows concurrent use of steps 3 and 4 to allow each learner a turn describing and performing the skill during the group rotation. 


  1. Krautter M, Weyrich P, Schultz JH. Effects of Peyton's Four-Step Approach on Objective Performance Measures in Technical Skills Training: A Controlled Trial. Teaching and Learning in Medicine, 23:3, 244-250
  2. Nikendei C, Huber J, Stiepak J. Modification of Peyton’s fur-step approach for small group teaching – a descriptive study. BMC Med Educ 2014; 14:68.
  3. Romero P, Günther P, Kowalewski KF. 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.

Author Information:

Julie Marshall, MD
Associate Professor of Clinical Anesthesiology
Residency Program Director
University of Missouri-Columbia

The SEA is proud to be a member-driven organization, dedicated to the teaching and development of future anesthesiologists, and to the advancement of those who educate them.

Contact Info:

Society for Education in Anesthesia
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