The Effect of Peyton’s Four-Step Method for Teaching Point-of-Care Ultrasound Psychomotor Skills: An Experimental Study

The Effect of Peyton’s Four-Step Method for Teaching Point-of-Care Ultrasound Psychomotor Skills: An Experimental Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Peyton’s Four-Step Method for Teaching Point-of-Care Ultrasound Psychomotor Skills: An Experimental Study Michael Breunig, Ryan Kingsley, Darrell Schroeder, Jason Kraus, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7695150/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Nov, 2025 Read the published version in The Ultrasound Journal → Version 1 posted You are reading this latest preprint version Abstract Background: Medical education commonly utilizes the “see one, do one” two-step approach for teaching psychomotor skills; however, recent evidence suggests that Peyton’s four-step method leads to superior learning. The effect of Peyton’s four-step method on long term skill retention is less apparent and has never been assessed for Point-of-Care Ultrasound (POCUS). The purpose of this research project was to evaluate the effectiveness of Peyton’s four-step method on teaching the POCUS psychomotor skills of image acquisition to novice learners. Additionally, this research project assessed the influence of Peyton’s four-step method at three different points in time during the skill acquisition phase, in the setting of ongoing deliberate skill practice. Methods: A single-blinded, repeated measures interventional study based on experimental design was completed. PA students from one large academic medical center were randomized into a control group (using the two-step method) and intervention group (using Peyton’s four-step method). Students were taught POCUS of the aorta, bladder, heart, lungs, and kidneys. Students' POCUS skills were assessed during the immediate, intermediate, and delayed learning phases. At each assessment, an organ-specific score and a total score were obtained. Scores were compared using a Wilcoxon rank sum test. An ordinal logistic regression analysis was performed using a generalized linear mixed model with a multinomial distribution and cumulative logit link function to assess overall effect of Peyton's four-step method. Results: Students who were taught using Peyton’s method were found to have an increased likelihood of higher total scores compared to those taught using usual instruction (OR = 4.2, p = 0.003). Peyton’s method was found to have increased likelihood of higher scores for cardiac (OR = 2.3, p = 0.032), lung (OR = 2.5, p = 0.034), and kidney (OR = 3.0, p = 0.015). Student performance statistically improved with Peyton’s four-step method during the immediate (p = 0.031) and delayed (p = 0.011) skill acquisition phases, but not in the intermediate phase. Conclusion: Peyton’s four-step method improves overall psychomotor skill acquisition for POCUS. Peyton’s four-step method specifically improved psychomotor skills in the immediate skill acquisition phase and the delayed skill acquisition phase. The benefit of Peyton’s four-step method was more prominent in higher complexity POCUS applications. Point-of-Care Ultrasound POCUS Bedside Ultrasound Psychomotor skills Medical Education Physician Assistant competency. Background Point-of-Care Ultrasound (POCUS) is an ultrasound examination, performed by a clinician, at a patient’s bedside to answer a specific diagnostic or therapeutic question. 1 , 2 In contrast to formal consultative ultrasonography, POCUS is quicker and expedites care. 3 – 6 POCUS has many clinical applications. It can be utilized to evaluate specific organ systems, such as the aorta, bladder, heart, lungs, kidneys, soft tissues, and upper and lower extremity deep veins. 2 , 7 – 11 Additionally, multi-organ system protocols have been developed to evaluate patients with respiratory failure, trauma, and shock. 8 , 9 , 12 Given its demonstrated utility, POCUS is increasingly being integrated into medical training, including medical school, residency, and Physician Assistant (PA) programs. 1 Thus, understanding the most effective ways to teach POCUS has widespread importance in medical education. POCUS involves concurrent utilization of both the cognitive and psychomotor domains of learning. POCUS training and assessment can generally be split into the components of basic knowledge (anatomy, physiology, ultrasound utilization), image acquisition (the psychomotor domain of utilizing the ultrasound to obtain high quality images), image interpretation (identifying normal findings and pathology on ultrasound images), and clinical integration (utilizing the generated images and interpretation to advance patient care). 2 , 13 Psychomotor image acquisition is an important distinguishing factor for POCUS from consultative ultrasonography and image acquisition is required prior to image interpretation in clinical practice. Additionally, poor image acquisition can impair image interpretation or lead to incorrect interpretation, adversely impacting care. 2 , 13 Thus, psychomotor image acquisition is of paramount importance in POCUS education. Psychomotor skill development requires repeated, deliberate practice to achieve mastery, which is true for POCUS image acquisition as well. 14 – 19 A recent systematic review demonstrated that while different POCUS applications require different amounts of practice, all require some degree of deliberate practice to improve performance. 15 Notably, more complicated applications, such as cardiac POCUS, and to a lesser extent aorta, lung, and renal POCUS, require more deliberate practice to achieve mastery than simpler applications, such as bladder POCUS. 15 , 16 Understanding the most effective way to teach psychomotor skills has significant implications in medical education. Improved psychomotor skill acquisition can lead to increased educational efficiency and potentially better patient outcomes. Psychomotor skills training in medical education programs have historically adopted a “see one, do one” two-step approach first proposed by Dr. Halsted in 1904, utilizing the steps of: 1. Demonstration - The entire skill is performed in real time, with limited commentary or teaching. 2. Performance - The learner completes the skill while receiving feedback from the teacher. 20 Despite its development over one hundred years ago, Halsted’s two-step approach is still commonly utilized in medical education. 21 Dr. JWR Peyton proposed a method for teaching clinical skills in 1998 utilizing four steps, based on his experience and observations training surgical residents. 22 Peyton’s four-step method includes: 1. Demonstration - The entire skill is performed in real time, with limited commentary or teaching. 2. Deconstruction - The teacher repeats the skill while explaining each component of the overall skill in detail. 3. Comprehension - The learner explains each component to the teacher, guiding them to complete the entire skill. 4. Performance - The learner completes the skill while receiving feedback from the teacher. 22 Peyton proposed this method to improve active engagement with the trainee, provide opportunities for immediate feedback, and enable remediation of surgical skills. This approach aligns with our evolving understanding of educational theory for psychomotor skill development. Specifically, Peyton’s four-step method provides contemporaneous feedback, mental practice, and deliberate practice, all shown to improve performance over time. 14 , 17 , 19 , 23 , 24 Moreover, recent evidence suggests Peyton’s four-step approach can lead to better learning outcomes for specific skills in medical education. 21 Peyton’s four-step method has been shown to improve immediate skill acquisition for medical skills; however, its effect on long term skill retention is less clear. 21 In addition, the effect of Peyton’s four-step method on longitudinal skill acquisition in the context of ongoing, required, deliberate skill practice has not been previously evaluated. Furthermore, it has been posited that Peyton’s four-step method is most beneficial for acquiring complex skills, and less so for relatively simple tasks. 25 For POCUS-related skills, studies have evaluated the effect of Peyton’s four-step method when teaching echocardiography skills and musculoskeletal ultrasound. 26 , 27 Both studies failed to show statistically significant benefit, but notably, both employed peer-to-peer teaching instead of teaching provided by those with expertise. The effect of Peyton’s four-step method on POCUS when taught by experienced healthcare providers has never been studied. The purpose of this study was to evaluate the effect of Peyton’s four-step method on POCUS image acquisition psychomotor skill development in the setting of ongoing deliberate skill practice. Secondarily, we assessed if the effect of Peyton's four-step method varied based on POCUS application or the phase of skill acquisition. The purpose of this research study was to evaluate the effect of Peyton’s four-step method on POCUS image acquisition psychomotor skill development in the setting of ongoing deliberate skill practice. Secondarily, this research study assessed if the effect of Peyton's four-step method varied based on POCUS application and during different phases of skill acquisition. Methods The study was deemed exempt by the academic medical center’s institutional review board (24-06851). A single-blinded, repeated measures experimental study was completed. Eligibility criteria included first year PA students from one large academic medical center. Exclusion criteria included students with prior ultrasound experience. Students were notified of classroom research and offered the opportunity to opt out of the study via email to a research coordinator, with faculty blinded to opt out information. Students who opted out of the research project would be placed in the control group to receive the standard education provided by the program. Utilizing simple randomization prepared by an independent statistician not involved in participant recruitment or data collection, all participants were randomized into a control group (using Halsted’s two-step method) and intervention group (using Peyton’s four-step method) to assess the influence of Peyton’s four-step approach on POCUS psychomotor skill development. This PA program has a well-established longitudinally integrated POCUS curriculum, that amongst others, covers the topics of aorta, bladder, cardiac, lung, and renal POCUS. 1 Students are assessed through various methods, including knowledge and interpretation-focused quizzes and tests, and hands-on skills examinations. Importantly, the curriculum also includes a POCUS portfolio that requires ongoing deliberate practice of POCUS skills throughout the study period. To maintain a four-to-one student-to-teacher ratio, six total practicing clinicians (physicians or PAs) with expertise in POCUS were recruited to be educators for the study. All educators were required to be credentialed to utilize POCUS in their local clinical practice and had experience with POCUS education to ensure a baseline level of competency. Educators were assigned to teach using either Peyton’s four-step method or Halsted’s two-step method. Education on aorta, bladder, cardiac, lung, and renal POCUS was provided to students over a two-month period, horizontally aligned with the rest of the PA program curriculum. Each hands-on skill received dedicated education comprised of two hours; first the skill was taught (either utilizing the two-step or four-step method), then followed by learner practice utilizing other colleagues as models. A script of the specific steps to teach each view for the organ-systems was utilized by educators in both the control and intervention groups to support standardization. All students received the same education on cognitive skills; however, psychomotor skills were taught based on their randomization. Following completion of the curriculum for aorta, bladder, cardiac, lung, and renal POCUS, students were assessed via hands-on skills examinations at three different intervals: in the immediate skill acquisition phase (one week after curriculum completion), the intermediate skill acquisition phase (one month after completion of the curriculum), and the delayed skill acquisition phase (four months after completion of the curriculum). Throughout the study, based on the prior curricular design, students were required to have continued deliberate practice of POCUS skills, submitting a minimum of eleven exams (two aorta, bladder, lung, and kidney; three cardiac) prior to the first assessment, an additional fourteen exams (two bladder; three aorta, cardiac, lung, and kidney) prior to the second assessment, and an additional twenty-five exams (four bladder; five aorta, lung, renal; six cardiac) prior to the third assessment. Three additional practicing clinicians with expertise in evaluation of PA student learners and POCUS were recruited to assess learner performance and were blinded to the randomization of the students. Students were assessed using a previously validated instrument titled, the “Observed Structured POCUS Readiness Exam” (OSPRE). 28 The OSPRE instrument evaluates learners on the following criteria: indication, ultrasound device utilization, purposeful examination, image depth, image axis, image gain, overall image quality, structure identification, interpretation, and application. All criteria are evaluated on a five-point Likert scale from very poor (1) to exemplary (5). Statistical Methods : At each assessment, organ specific OSPRE scores were obtained for aorta, bladder, cardiac, lung, renal POCUS and a total score was calculated as the sum of the organ specific scores. Scores were summarized for each assessment using median (Q1, Q3) and compared between treatment groups using the Wilcoxon rank sum test. In addition, using data from all assessments an ordinal logistic regression analysis was performed using a generalized linear mixed model with a multinomial distribution and cumulative logit link function. For this model, the independent variable was treatment (Peyton’s four-step method vs usual instruction), time-period was included as a covariate, and student was included as a random effect. Results from the ordinal logistic regression analyses were summarized by presenting the odds ratio (OR) and 95% lower confidence bound (LCB) for the treatment effect, where odds ratios greater than 1.0 indicate an increased likelihood of higher scores for students who were taught using Peyton’s method versus usual instruction. In all cases, one-tailed p-values were presented with p < 0.05 considered statistically significant. Results The PA program matriculated 25 students into the cohort that participated in the study. Unrelated to the study, one student decelerated from the cohort of learners, and one additional student had prior ultrasound experience. Both students were excluded from the study. Twenty-three of the twenty-three eligible students participated in the study. Based on randomization, eleven students were in the control group and twelve were in the intervention group. All 23 students completed the teaching sessions, image portfolio, and assessments associated with the study without any participant crossover or missing data. All twenty-three students completed one examination of each organ system (aorta, bladder, cardiac, lung, and renal) at three individual times, totaling fifteen examinations per student. Over the course of the research project, 345 individual examinations were completed during hands on skills assessments: sixty-nine per organ system. OSPRE scores are summarized in Table 1 . The median (Q1, Q3) total score for students taught using Peyton’s method versus usual instruction was 190 (185, 192) vs 178 (177, 186) at the immediate assessment, 190 (186, 195) vs 187 (180, 197) at the intermediate assessment and 198 (185, 199) vs 193 (188, 195) at the delayed assessment; with significant differences observed at the immediate (p = 0.031) and delayed (p = 0.011) assessments. From a repeated measures analysis which included data from all assessments, students who were taught using Peyton’s method were found to have an increased likelihood of higher total scores compared to those taught using usual instruction (OR = 4.2, p = 0.003). From the repeated measures analyses of the organ-specific OSPRE scores, students taught using Peyton’s method were found to have an increased likelihood of higher scores for cardiac (OR = 2.3, p = 0.032), lung (OR = 2.5, p = 0.034), and kidney (OR = 3.0, p = 0.015). Non-statistically significant improvements were noted for aorta (OR = 2.7, p = 0.58) and bladder (OR = 1.7, p = 0.121). Table 1 POCUS Assessment Results * Peyton’s Method Usual Instruction Component (N = 12) (N = 11) p-value † Cardiac score Immediate 38 (35, 39) 36 (35, 40) 0.351 Intermediate 37 (36, 39) 35 (34, 38) 0.178 Delayed 40 (39, 40) 38 (34, 40) 0.034 Overall Treatment Effect ‡ : OR = 2.3, LCB = 1.1, p = 0.032 Lung score Immediate 38 (33, 39) 35 (33, 39) 0.256 Intermediate 40 (37, 40) 39 (32, 40) 0.199 Delayed 40 (40, 40) 40 (38, 40) 0.028 Overall Treatment Effect ‡ : OR = 2.5, LCB = 1.1, p = 0.034 Kidney score Immediate 39 (38, 40) 36 (33, 39) 0.018 Intermediate 39 (39, 40) 39 (38, 40) 0.372 Delayed 40 (38, 40) 39 (37, 40) 0.087 Overall Treatment Effect ‡ : OR = 3.0, LCB = 1.3, p = 0.015 Bladder score Immediate 40 (38, 40) 38 (37, 40) 0.169 Intermediate 39 (38, 40) 39 (39, 40) 0.600 Delayed 40 (39, 40) 39 (38, 40) 0.084 Overall Treatment Effect ‡ : OR = 1.7, LCB = 0.8, p = 0.121 Aorta score Immediate 38 (37, 40) 38 (35, 39) 0.225 Intermediate 39 (37, 40) 39 (37, 40) 0.395 Delayed 40 (39, 40) 38 (37, 39) 0.009 Overall Treatment Effect ‡ : OR = 2.7, LCB = 1.0, p = 0.058 Total score Immediate 190 (185, 192) 178 (177, 186) 0.031 Intermediate 190 (186, 195) 187 (180, 197) 0.298 Delayed 198 (195, 199) 193 (188, 195) 0.011 Overall Treatment Effect ‡ : OR = 4.2, LCB = 2.0, p = 0.003 *Assessment scores are summarized using median (25th, 75th ). †Wilcoxon rank sum test, one-tailed exact p-value. ‡The overall treatment effect was obtained from an ordinal logistic regression analysis performed using a generalized linear mixed model with a multinomial distribution and cumulative logit link function. For this model, the independent variable was treatment (Peyton’s method vs usual instruction), time-period was included as a covariate, and student was included as a random effect. Results are summarized by presenting the odds ratio (OR) and 95% lower confidence bound (LCB) for the treatment effect along with the associated one-tailed p-value. Discussion Peyton’s four-step method has previously been shown to improve overall psychomotor skill development for specific procedures in medical education. 21 This study further supports this finding and adds to the evidence that Peyton’s four-step method is more effective for teaching medical skills than the two-step method. Importantly, however, this is the first study to show superiority of Peyton’s four-step method specifically for teaching POCUS psychomotor skills. In addition, this is the first study to evaluate Peyton's four-step method for teaching POCUS skills using expert teachers. Two prior studies have evaluated the effect of Peyton’s four-step method to teach echocardiography skills, a skill adjacent to cardiac POCUS, and musculoskeletal ultrasound skills. 26 , 27 However, both studies used a peer-to-peer teaching model and failed to show a statistically significant difference in the teaching modalities. As such, authors have hypothesized that Peyton’s four-step method is most beneficial when utilized by experts. 26 The findings of improved POCUS skill development when educators use Peyton’s four-step method has significant impacts on curricular design and training modalities. Educators of novice POCUS learners should teach POCUS psychomotor skills using Peyton’s four-step method to improve learner performance. Prior research has not clearly defined the impact of Peyton’s four-step method after the initial skill acquisition phase. In their systematic review and meta-analysis, Giacomino, Caliesch, and Sattelmayer (2020), evaluated the effect of Peyton’s four-step method on skill retention with repeated measures, finding an effect size of a 0.7 SMD (95% CI [-0.09-1.49]). 21 Importantly, only five studies included in the systematic review and meta-analysis included repeated measures. 29–32 While a trend towards improvement was noted, it was not found to be statistically significant. Additionally, since the publication of the systematic review and meta-analysis, Peyton’s four-step method had no significant benefit on repeat test after six months for teaching forearm casting when compared to the two-step method. 33 Ours is the first study to assess the effect of Peyton’s four-step method on longitudinal skill acquisition in the setting on ongoing, deliberate practice. In our study, Peyton’s four-step method had statistically significant benefit in the immediate and delayed skill acquisition phase, but not the intermediate phase. The reason behind these findings remains unclear, however, the difference may relate to the theoretical foundations of motor learning. Fitts and Posner (1967) posited that learners progress through three stages while developing motor skills; 1.) the cognitive phase (skills require significant cognitive effort, performance is slow, resulting in many errors, and is based on mimicking movements and trial and error), 2.) the associative phase (skills require less cognitive effort, performance improves quickly, errors reduce, and learners can adapt movements more naturally), and 3.) the autonomous phase (skills are increasingly autonomous and of high quality, but further improvement ceases or decreases its rate). 18 We hypothesize that improved performance in the immediate and delayed skill acquisition phases, but not in the intermediate phase represents differing rates of progression through Fitts and Posner’s stages of motor learning. This is important for multiple reasons. The findings of this study suggest that Peyton’s four-step method enhances performance in the cognitive stage, immediately after learners are taught the skill. Additionally, longitudinal skill acquisition for POCUS can be expedited using Peyton’s four-step method. This is demonstrated by the improved performance overall, and specifically in the delayed skill acquisition phase, despite similar amounts of deliberate practice. Theoretically, learners taught with Peyton’s four-step method might require less deliberate practice to progress toward more autonomous performance of a skill. Importantly, learners taught with Halsted’s two-step method can likely achieve similar levels of performance, just at slower rates or after relatively more deliberate practice. This is the first time this benefit has been reported in the literature. Peyton’s four-step method was originally described as a way of acquiring complex clinical skills pertaining to operative procedures (Peyton, 1998) and prior researchers have hypothesized that it is most beneficial for development of complex skills. 22 , 25 Our study supports this hypothesis, as Peyton’s four-step method was not beneficial for bladder POCUS, a relatively easy skill based on prior studies, but was for considerably harder skills, such as cardiac, lung, and renal POCUS. 15 , 16 Prior research has shown that the learning curve of aorta POCUS is similar to lung and renal POCUS. 16 It is notable that in our study, a statistically significant benefit for Peyton’s four-step method on aorta POCUS was not noticed, however, there was a trend toward improvement (OR = 2.7, LCB = 1.0, p = 0.058). It is possible that a larger sample would have resulted in a statistically significant finding. This application-specific difference within a singular skill has never been demonstrated before. Educators should prioritize the use of Peyton’s four-step method for complex medical skills; however, the two-step method is likely sufficient for relatively simple tasks. This research project has several limitations. The small sample size, sampling methods, and study sample (PA students only) limit the generalizability of the findings. However, novice PA students have similar learning curves to other novice medical learners, therefore it would be reasonable to generalize our findings to other novice learners. 15 , 16 Additionally, between assessments, learners may have practiced POCUS skills with individuals taught via the other method and peer-to-peer teaching during these informal practice sessions is likely. It is unclear how this might affect the results of the study. However, given the results, it is unlikely this would have improved the performance of the intervention group and would have more likely diminished the difference between the groups. Given these limitations, further studies with larger samples or multiple learner types should be completed to replicate these findings, increasing generalizability. The final skill assessment in this study occurred after a minimum of eight bladder examinations, ten aorta, lung, and renal examinations, and twelve cardiac examinations. Current evidence suggests that, except for bladder POCUS, psychomotor skill levels generally plateau after fifteen or more examinations and guidelines recommend a minimum of twenty-five exams be completed per organ system. 12 , 16 Future research should assess the long-term effect of the use of Peyton’s four-step method after additional deliberate practice. Research comparing learning curves between students taught with Peyton’s four-step method and the standard, two-step method after completion of the guideline-recommended 25 POCUS examinations, should be considered. Alternatively, performance on a hands-on skills examination, as utilized in this study, could be compared after a prolonged period of deliberate practice, such as at the time of graduation from the PA program. Conclusion Peyton’s four-step method improves overall psychomotor skill acquisition for POCUS. This is the first study to demonstrate that Peyton’s four-step method improves longitudinal performance in the setting of ongoing, deliberate skill practice. Peyton’s four-step method specifically improved psychomotor skills in the immediate skill acquisition phase and the delayed skill acquisition phase. The benefit to Peyton’s four-step method was noted in more complex POCUS applications, such as cardiac, lung, and renal POCUS; supporting use of Peyton’s method to teach complicated procedures. Abbreviations OSPRE; Observed Structured POCUS Readiness Exam PA; Physician Assistant POCUS; Point-of-Care Ultrasound Declarations Ethics approval and consent to participate: The research proposal was deemed exempt by the Mayo Clinic institutional review board (24-006851) in accordance with the Declaration of Helsinki. Informed consent to participate was obtained after students were notified of the purpose, procedures, risks, benefits, and data storage processes. Consent for publication: Not Applicable. Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors report no financial and non-financial competing interests. Funding: Endowment for Educational Research Award from the Mayo Clinic Office of Applied Scholarship and Education Science. Authors' contributions: MB developed the research question and study design, implemented the study, including obtaining IRB approval and securing funding, and wrote the manuscript. RK assisted with study design and learner assessment. DS assisted with statistical analysis and writing of the methods/results sections. JK and CP assisted with the learner assessment. TG, LB, TR, HR, WS, RS, and MI assisted with learner education. DK assisted with study design, IRB development, and mentorship of the primary author. All authors reviewed and edited the manuscript prior to submission. Acknowledgements: The authors would like to acknowledge the Mayo Clinic Office of Applied Scholarship and Education Science. Additionally, they would like to acknowledge Drs. Burl Haar, Rustin Wolfe, and Catherine Ford from Saint Mary’s University of Minnesota. 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Neuropsychologia . 10.1016/0028-3932(95)00073-C Jeannerod M (2001) Neural simulation of action: a unifying mechanism for motor cognition. Neuroimage . /07// 2001;14(1 Pt 2):S103-109. 10.1006/nimg.2001.0832 Münster T, Stosch C, Hindrichs N, Franklin J, Matthes J (2016) Peyton's 4-Steps-Approach in comparison: Medium-term effects on learning external chest compression - a pilot study. GMS J Med Educ 2016 33(4):Doc60. 10.3205/zma001059 Gradl-Dietsch G, Hitpaß L, Gueorguiev B, Nebelung S, Schrading S, Knobe M (2019) Undergraduate Curricular Training in Musculoskeletal Ultrasound by Student Teachers: The Impact of Peyton's Four-Step Approach. Z Orthop Unfall 157(3):270–278 2019/06//. 10.1055/a-0715-2435 Gradl-Dietsch G, Menon AK, Gürsel A et al (2018) Basic echocardiography for undergraduate students: a comparison of different peer-teaching approaches. Eur J Trauma Emerg Surg . /02// 2018;44(1):143–152. 10.1007/s00068-017-0819-1 Additional Declarations No competing interests reported. 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Breunig","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACAzjJzMAGJC3koBLMRGuRMCZSCwSAtSQ2ENJiLn34mHRBQS2Dbjvzswc/KiTS17afMXzAUGEN04sBLPvS0qRnGBxnMDvMZm7Yc0Yid9uZHGMDhjPpOLUYnOExk+YxOAbUwsMmwdsG1HIgx0yCse0wHi383+BaJP/+k0g3O/8GqOUfPi08bEAtNWAt0rwNEglmN0C2NODWYtnDZmzNY3CAB+gXM2mZYxKG2248KzZIOJZujEuLOQ/zw9s8f+rkzM4ffib5psZG3ux88sYHH2qsZXFpgYLDPEgcDgOGBPzKQaAOmcP+gLCGUTAKRsEoGEkAANIhUMrl26bJAAAAAElFTkSuQmCC","orcid":"","institution":"Mayo Clinic","correspondingAuthor":true,"prefix":"","firstName":"Michael","middleName":"","lastName":"Breunig","suffix":""},{"id":525308674,"identity":"4732f29f-4913-43e9-b035-68e5f4f8030e","order_by":1,"name":"Ryan Kingsley","email":"","orcid":"","institution":"Mayo 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Clinic","correspondingAuthor":false,"prefix":"","firstName":"Corbin","middleName":"","lastName":"Plooster","suffix":""},{"id":525308678,"identity":"cacad22b-a242-4e9e-8937-5d20885c2b97","order_by":5,"name":"Tiffany Galusch","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Tiffany","middleName":"","lastName":"Galusch","suffix":""},{"id":525308679,"identity":"81ac063e-086f-429c-80af-34bdb3d1ee8c","order_by":6,"name":"Laura Boldenow","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Boldenow","suffix":""},{"id":525308680,"identity":"36c78e10-b737-492d-8a05-3f90ffdf9468","order_by":7,"name":"Taryn Ragaisis","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Taryn","middleName":"","lastName":"Ragaisis","suffix":""},{"id":525308681,"identity":"10796d0f-e59b-444c-b98d-f25a79590c72","order_by":8,"name":"Hannah Regan","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"Regan","suffix":""},{"id":525308682,"identity":"cfe549a4-3443-4a8c-bef0-d8cde82774e9","order_by":9,"name":"Will Schouten","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Will","middleName":"","lastName":"Schouten","suffix":""},{"id":525308683,"identity":"87040cdf-1600-48fc-939f-2d4fba431539","order_by":10,"name":"Raheel Shafay","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Raheel","middleName":"","lastName":"Shafay","suffix":""},{"id":525308684,"identity":"6d3293ea-bd91-4d76-b65e-8244f4a7bdc5","order_by":11,"name":"Meltiady Issa","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Meltiady","middleName":"","lastName":"Issa","suffix":""},{"id":525308685,"identity":"5baae059-a5e4-4699-ab11-d470bff6b93d","order_by":12,"name":"Deanne Kashiwagi","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Deanne","middleName":"","lastName":"Kashiwagi","suffix":""}],"badges":[],"createdAt":"2025-09-23 13:53:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7695150/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7695150/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13089-025-00466-w","type":"published","date":"2025-11-11T15:57:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92996969,"identity":"024c4b9b-9a7f-4d5f-b5d6-eace43f2b41f","added_by":"auto","created_at":"2025-10-08 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03:49:22","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82378,"visible":true,"origin":"","legend":"","description":"","filename":"031f8000341e45e9a5c9b978d73964f71enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7695150/v1/feb391b81dc6020f632e22db.xml"},{"id":92996971,"identity":"a74bd6b4-7c64-45f7-ac1d-5dd02dfe03b0","added_by":"auto","created_at":"2025-10-08 03:41:22","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80171,"visible":true,"origin":"","legend":"","description":"","filename":"031f8000341e45e9a5c9b978d73964f71structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7695150/v1/88b6f8f7945e1b2b2dbf1ba1.xml"},{"id":92997213,"identity":"cf0431ec-03d0-4c7b-88ac-a4e0eccab7d9","added_by":"auto","created_at":"2025-10-08 03:49:22","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91220,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7695150/v1/15a71212929c1efa25f2d6e0.html"},{"id":96105198,"identity":"524ba4e8-8d4f-4292-b8ff-cec48e988aeb","added_by":"auto","created_at":"2025-11-17 16:09:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":533606,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7695150/v1/a391c7c5-5c30-4762-8407-6bb9f4f50fd7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of Peyton’s Four-Step Method for Teaching Point-of-Care Ultrasound Psychomotor Skills: An Experimental Study","fulltext":[{"header":"Background","content":"\u003cp\u003ePoint-of-Care Ultrasound (POCUS) is an ultrasound examination, performed by a clinician, at a patient\u0026rsquo;s bedside to answer a specific diagnostic or therapeutic question.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In contrast to formal consultative ultrasonography, POCUS is quicker and expedites care.\u003csup\u003e\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e POCUS has many clinical applications. It can be utilized to evaluate specific organ systems, such as the aorta, bladder, heart, lungs, kidneys, soft tissues, and upper and lower extremity deep veins.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Additionally, multi-organ system protocols have been developed to evaluate patients with respiratory failure, trauma, and shock.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Given its demonstrated utility, POCUS is increasingly being integrated into medical training, including medical school, residency, and Physician Assistant (PA) programs.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Thus, understanding the most effective ways to teach POCUS has widespread importance in medical education.\u003c/p\u003e\u003cp\u003ePOCUS involves concurrent utilization of both the cognitive and psychomotor domains of learning. POCUS training and assessment can generally be split into the components of basic knowledge (anatomy, physiology, ultrasound utilization), image acquisition (the psychomotor domain of utilizing the ultrasound to obtain high quality images), image interpretation (identifying normal findings and pathology on ultrasound images), and clinical integration (utilizing the generated images and interpretation to advance patient care).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Psychomotor image acquisition is an important distinguishing factor for POCUS from consultative ultrasonography and image acquisition is required prior to image interpretation in clinical practice. Additionally, poor image acquisition can impair image interpretation or lead to incorrect interpretation, adversely impacting care.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Thus, psychomotor image acquisition is of paramount importance in POCUS education.\u003c/p\u003e\u003cp\u003ePsychomotor skill development requires repeated, deliberate practice to achieve mastery, which is true for POCUS image acquisition as well.\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e A recent systematic review demonstrated that while different POCUS applications require different amounts of practice, all require some degree of deliberate practice to improve performance.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Notably, more complicated applications, such as cardiac POCUS, and to a lesser extent aorta, lung, and renal POCUS, require more deliberate practice to achieve mastery than simpler applications, such as bladder POCUS.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eUnderstanding the most effective way to teach psychomotor skills has significant implications in medical education. Improved psychomotor skill acquisition can lead to increased educational efficiency and potentially better patient outcomes. Psychomotor skills training in medical education programs have historically adopted a \u0026ldquo;see one, do one\u0026rdquo; two-step approach first proposed by Dr. Halsted in 1904, utilizing the steps of:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e1. Demonstration - The entire skill is performed in real time, with limited commentary or teaching.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e2. Performance - The learner completes the skill while receiving feedback from the teacher.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eDespite its development over one hundred years ago, Halsted\u0026rsquo;s two-step approach is still commonly utilized in medical education.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDr. JWR Peyton proposed a method for teaching clinical skills in 1998 utilizing four steps, based on his experience and observations training surgical residents.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Peyton\u0026rsquo;s four-step method includes:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e1. Demonstration - The entire skill is performed in real time, with limited commentary or teaching.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e2. Deconstruction - The teacher repeats the skill while explaining each component of the overall skill in detail.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e3. Comprehension - The learner explains each component to the teacher, guiding them to complete the entire skill.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e4. Performance - The learner completes the skill while receiving feedback from the teacher.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003ePeyton proposed this method to improve active engagement with the trainee, provide opportunities for immediate feedback, and enable remediation of surgical skills. This approach aligns with our evolving understanding of educational theory for psychomotor skill development. Specifically, Peyton\u0026rsquo;s four-step method provides contemporaneous feedback, mental practice, and deliberate practice, all shown to improve performance over time.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Moreover, recent evidence suggests Peyton\u0026rsquo;s four-step approach can lead to better learning outcomes for specific skills in medical education.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePeyton\u0026rsquo;s four-step method has been shown to improve immediate skill acquisition for medical skills; however, its effect on long term skill retention is less clear.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In addition, the effect of Peyton\u0026rsquo;s four-step method on longitudinal skill acquisition in the context of ongoing, required, deliberate skill practice has not been previously evaluated. Furthermore, it has been posited that Peyton\u0026rsquo;s four-step method is most beneficial for acquiring complex skills, and less so for relatively simple tasks.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e For POCUS-related skills, studies have evaluated the effect of Peyton\u0026rsquo;s four-step method when teaching echocardiography skills and musculoskeletal ultrasound.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Both studies failed to show statistically significant benefit, but notably, both employed peer-to-peer teaching instead of teaching provided by those with expertise. The effect of Peyton\u0026rsquo;s four-step method on POCUS when taught by experienced healthcare providers has never been studied.\u003c/p\u003e\u003cp\u003eThe purpose of this study was to evaluate the effect of Peyton\u0026rsquo;s four-step method on POCUS image acquisition psychomotor skill development in the setting of ongoing deliberate skill practice. Secondarily, we assessed if the effect of Peyton's four-step method varied based on POCUS application or the phase of skill acquisition. The purpose of this research study was to evaluate the effect of Peyton\u0026rsquo;s four-step method on POCUS image acquisition psychomotor skill development in the setting of ongoing deliberate skill practice. Secondarily, this research study assessed if the effect of Peyton's four-step method varied based on POCUS application and during different phases of skill acquisition.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The study was deemed exempt by the academic medical center\u0026rsquo;s institutional review board (24-06851). A single-blinded, repeated measures experimental study was completed. Eligibility criteria included first year PA students from one large academic medical center. Exclusion criteria included students with prior ultrasound experience. Students were notified of classroom research and offered the opportunity to opt out of the study via email to a research coordinator, with faculty blinded to opt out information. Students who opted out of the research project would be placed in the control group to receive the standard education provided by the program. Utilizing simple randomization prepared by an independent statistician not involved in participant recruitment or data collection, all participants were randomized into a control group (using Halsted\u0026rsquo;s two-step method) and intervention group (using Peyton\u0026rsquo;s four-step method) to assess the influence of Peyton\u0026rsquo;s four-step approach on POCUS psychomotor skill development. This PA program has a well-established longitudinally integrated POCUS curriculum, that amongst others, covers the topics of aorta, bladder, cardiac, lung, and renal POCUS.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Students are assessed through various methods, including knowledge and interpretation-focused quizzes and tests, and hands-on skills examinations. Importantly, the curriculum also includes a POCUS portfolio that requires ongoing deliberate practice of POCUS skills throughout the study period.\u003c/p\u003e\u003cp\u003eTo maintain a four-to-one student-to-teacher ratio, six total practicing clinicians (physicians or PAs) with expertise in POCUS were recruited to be educators for the study. All educators were required to be credentialed to utilize POCUS in their local clinical practice and had experience with POCUS education to ensure a baseline level of competency. Educators were assigned to teach using either Peyton\u0026rsquo;s four-step method or Halsted\u0026rsquo;s two-step method. Education on aorta, bladder, cardiac, lung, and renal POCUS was provided to students over a two-month period, horizontally aligned with the rest of the PA program curriculum. Each hands-on skill received dedicated education comprised of two hours; first the skill was taught (either utilizing the two-step or four-step method), then followed by learner practice utilizing other colleagues as models. A script of the specific steps to teach each view for the organ-systems was utilized by educators in both the control and intervention groups to support standardization. All students received the same education on cognitive skills; however, psychomotor skills were taught based on their randomization.\u003c/p\u003e\u003cp\u003eFollowing completion of the curriculum for aorta, bladder, cardiac, lung, and renal POCUS, students were assessed via hands-on skills examinations at three different intervals: in the immediate skill acquisition phase (one week after curriculum completion), the intermediate skill acquisition phase (one month after completion of the curriculum), and the delayed skill acquisition phase (four months after completion of the curriculum). Throughout the study, based on the prior curricular design, students were required to have continued deliberate practice of POCUS skills, submitting a minimum of eleven exams (two aorta, bladder, lung, and kidney; three cardiac) prior to the first assessment, an additional fourteen exams (two bladder; three aorta, cardiac, lung, and kidney) prior to the second assessment, and an additional twenty-five exams (four bladder; five aorta, lung, renal; six cardiac) prior to the third assessment. Three additional practicing clinicians with expertise in evaluation of PA student learners and POCUS were recruited to assess learner performance and were blinded to the randomization of the students. Students were assessed using a previously validated instrument titled, the \u0026ldquo;Observed Structured POCUS Readiness Exam\u0026rdquo; (OSPRE).\u003csup\u003e28\u003c/sup\u003e The OSPRE instrument evaluates learners on the following criteria: indication, ultrasound device utilization, purposeful examination, image depth, image axis, image gain, overall image quality, structure identification, interpretation, and application. All criteria are evaluated on a five-point Likert scale from very poor (1) to exemplary (5).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStatistical Methods\u003c/span\u003e:\u003c/h2\u003e\u003cp\u003eAt each assessment, organ specific OSPRE scores were obtained for aorta, bladder, cardiac, lung, renal POCUS and a total score was calculated as the sum of the organ specific scores. Scores were summarized for each assessment using median (Q1, Q3) and compared between treatment groups using the Wilcoxon rank sum test. In addition, using data from all assessments an ordinal logistic regression analysis was performed using a generalized linear mixed model with a multinomial distribution and cumulative logit link function. For this model, the independent variable was treatment (Peyton\u0026rsquo;s four-step method vs usual instruction), time-period was included as a covariate, and student was included as a random effect. Results from the ordinal logistic regression analyses were summarized by presenting the odds ratio (OR) and 95% lower confidence bound (LCB) for the treatment effect, where odds ratios greater than 1.0 indicate an increased likelihood of higher scores for students who were taught using Peyton\u0026rsquo;s method versus usual instruction. In all cases, one-tailed p-values were presented with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e The PA program matriculated 25 students into the cohort that participated in the study. Unrelated to the study, one student decelerated from the cohort of learners, and one additional student had prior ultrasound experience. Both students were excluded from the study. Twenty-three of the twenty-three eligible students participated in the study. Based on randomization, eleven students were in the control group and twelve were in the intervention group. All 23 students completed the teaching sessions, image portfolio, and assessments associated with the study without any participant crossover or missing data. All twenty-three students completed one examination of each organ system (aorta, bladder, cardiac, lung, and renal) at three individual times, totaling fifteen examinations per student. Over the course of the research project, 345 individual examinations were completed during hands on skills assessments: sixty-nine per organ system.\u003c/p\u003e\u003cp\u003eOSPRE scores are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The median (Q1, Q3) total score for students taught using Peyton\u0026rsquo;s method versus usual instruction was 190 (185, 192) vs 178 (177, 186) at the immediate assessment, 190 (186, 195) vs 187 (180, 197) at the intermediate assessment and 198 (185, 199) vs 193 (188, 195) at the delayed assessment; with significant differences observed at the immediate (p\u0026thinsp;=\u0026thinsp;0.031) and delayed (p\u0026thinsp;=\u0026thinsp;0.011) assessments. From a repeated measures analysis which included data from all assessments, students who were taught using Peyton\u0026rsquo;s method were found to have an increased likelihood of higher total scores compared to those taught using usual instruction (OR\u0026thinsp;=\u0026thinsp;4.2, p\u0026thinsp;=\u0026thinsp;0.003). From the repeated measures analyses of the organ-specific OSPRE scores, students taught using Peyton\u0026rsquo;s method were found to have an increased likelihood of higher scores for cardiac (OR\u0026thinsp;=\u0026thinsp;2.3, p\u0026thinsp;=\u0026thinsp;0.032), lung (OR\u0026thinsp;=\u0026thinsp;2.5, p\u0026thinsp;=\u0026thinsp;0.034), and kidney (OR\u0026thinsp;=\u0026thinsp;3.0, p\u0026thinsp;=\u0026thinsp;0.015). Non-statistically significant improvements were noted for aorta (OR\u0026thinsp;=\u0026thinsp;2.7, p\u0026thinsp;=\u0026thinsp;0.58) and bladder (OR\u0026thinsp;=\u0026thinsp;1.7, p\u0026thinsp;=\u0026thinsp;0.121).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePOCUS Assessment Results\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeyton\u0026rsquo;s Method\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUsual Instruction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComponent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCardiac score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (35, 39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (35, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.351\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (36, 39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (34, 38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.178\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (39, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (34, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eOverall Treatment Effect\u003csup\u003e\u0026Dagger;\u003c/sup\u003e: OR\u0026thinsp;=\u0026thinsp;2.3, LCB\u0026thinsp;=\u0026thinsp;1.1, p\u0026thinsp;=\u0026thinsp;0.032\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLung score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (33, 39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (33, 39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.256\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (37, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (32, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.199\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (40, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (38, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eOverall Treatment Effect\u003csup\u003e\u0026Dagger;\u003c/sup\u003e: OR\u0026thinsp;=\u0026thinsp;2.5, LCB\u0026thinsp;=\u0026thinsp;1.1, p\u0026thinsp;=\u0026thinsp;0.034\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKidney score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (38, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (33, 39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.018\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (39, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (38, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (38, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (37, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.087\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eOverall Treatment Effect\u003csup\u003e\u0026Dagger;\u003c/sup\u003e: OR\u0026thinsp;=\u0026thinsp;3.0, LCB\u0026thinsp;=\u0026thinsp;1.3, p\u0026thinsp;=\u0026thinsp;0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBladder score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (38, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (37, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.169\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (38, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (39, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.600\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (39, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (38, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.084\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eOverall Treatment Effect\u003csup\u003e\u0026Dagger;\u003c/sup\u003e: OR\u0026thinsp;=\u0026thinsp;1.7, LCB\u0026thinsp;=\u0026thinsp;0.8, p\u0026thinsp;=\u0026thinsp;0.121\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAorta score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (37, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (35, 39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.225\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (37, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (37, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.395\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (39, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (37, 39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eOverall Treatment Effect\u003csup\u003e\u0026Dagger;\u003c/sup\u003e: OR\u0026thinsp;=\u0026thinsp;2.7, LCB\u0026thinsp;=\u0026thinsp;1.0, p\u0026thinsp;=\u0026thinsp;0.058\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190 (185, 192)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e178 (177, 186)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190 (186, 195)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e187 (180, 197)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.298\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelayed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e198 (195, 199)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e193 (188, 195)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eOverall Treatment Effect\u003csup\u003e\u0026Dagger;\u003c/sup\u003e: OR\u0026thinsp;=\u0026thinsp;4.2, LCB\u0026thinsp;=\u0026thinsp;2.0, p\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Assessment scores are summarized using median (25th, 75th ).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026dagger;Wilcoxon rank sum test, one-tailed exact p-value.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026Dagger;The overall treatment effect was obtained from an ordinal logistic regression analysis performed using a generalized linear mixed model with a multinomial distribution and cumulative logit link function. For this model, the independent variable was treatment (Peyton\u0026rsquo;s method vs usual instruction), time-period was included as a covariate, and student was included as a random effect. Results are summarized by presenting the odds ratio (OR) and 95% lower confidence bound (LCB) for the treatment effect along with the associated one-tailed p-value.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePeyton\u0026rsquo;s four-step method has previously been shown to improve overall psychomotor skill development for specific procedures in medical education.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e This study further supports this finding and adds to the evidence that Peyton\u0026rsquo;s four-step method is more effective for teaching medical skills than the two-step method. Importantly, however, this is the first study to show superiority of Peyton\u0026rsquo;s four-step method specifically for teaching POCUS psychomotor skills. In addition, this is the first study to evaluate Peyton's four-step method for teaching POCUS skills using expert teachers. Two prior studies have evaluated the effect of Peyton\u0026rsquo;s four-step method to teach echocardiography skills, a skill adjacent to cardiac POCUS, and musculoskeletal ultrasound skills.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e However, both studies used a peer-to-peer teaching model and failed to show a statistically significant difference in the teaching modalities. As such, authors have hypothesized that Peyton\u0026rsquo;s four-step method is most beneficial when utilized by experts.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e The findings of improved POCUS skill development when educators use Peyton\u0026rsquo;s four-step method has significant impacts on curricular design and training modalities. Educators of novice POCUS learners should teach POCUS psychomotor skills using Peyton\u0026rsquo;s four-step method to improve learner performance.\u003c/p\u003e\u003cp\u003ePrior research has not clearly defined the impact of Peyton\u0026rsquo;s four-step method after the initial skill acquisition phase. In their systematic review and meta-analysis, Giacomino, Caliesch, and Sattelmayer (2020), evaluated the effect of Peyton\u0026rsquo;s four-step method on skill retention with repeated measures, finding an effect size of a 0.7 SMD (95% CI [-0.09-1.49]).\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Importantly, only five studies included in the systematic review and meta-analysis included repeated measures.\u003csup\u003e29\u0026ndash;32\u003c/sup\u003e While a trend towards improvement was noted, it was not found to be statistically significant. Additionally, since the publication of the systematic review and meta-analysis, Peyton\u0026rsquo;s four-step method had no significant benefit on repeat test after six months for teaching forearm casting when compared to the two-step method.\u003csup\u003e33\u003c/sup\u003e Ours is the first study to assess the effect of Peyton\u0026rsquo;s four-step method on longitudinal skill acquisition in the setting on ongoing, deliberate practice. In our study, Peyton\u0026rsquo;s four-step method had statistically significant benefit in the immediate and delayed skill acquisition phase, but not the intermediate phase. The reason behind these findings remains unclear, however, the difference may relate to the theoretical foundations of motor learning. Fitts and Posner (1967) posited that learners progress through three stages while developing motor skills; 1.) the cognitive phase (skills require significant cognitive effort, performance is slow, resulting in many errors, and is based on mimicking movements and trial and error), 2.) the associative phase (skills require less cognitive effort, performance improves quickly, errors reduce, and learners can adapt movements more naturally), and 3.) the autonomous phase (skills are increasingly autonomous and of high quality, but further improvement ceases or decreases its rate).\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e We hypothesize that improved performance in the immediate and delayed skill acquisition phases, but not in the intermediate phase represents differing rates of progression through Fitts and Posner\u0026rsquo;s stages of motor learning. This is important for multiple reasons. The findings of this study suggest that Peyton\u0026rsquo;s four-step method enhances performance in the cognitive stage, immediately after learners are taught the skill. Additionally, longitudinal skill acquisition for POCUS can be expedited using Peyton\u0026rsquo;s four-step method. This is demonstrated by the improved performance overall, and specifically in the delayed skill acquisition phase, despite similar amounts of deliberate practice. Theoretically, learners taught with Peyton\u0026rsquo;s four-step method might require less deliberate practice to progress toward more autonomous performance of a skill. Importantly, learners taught with Halsted\u0026rsquo;s two-step method can likely achieve similar levels of performance, just at slower rates or after relatively more deliberate practice. This is the first time this benefit has been reported in the literature.\u003c/p\u003e\u003cp\u003ePeyton\u0026rsquo;s four-step method was originally described as a way of acquiring complex clinical skills pertaining to operative procedures (Peyton, 1998) and prior researchers have hypothesized that it is most beneficial for development of complex skills.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Our study supports this hypothesis, as Peyton\u0026rsquo;s four-step method was not beneficial for bladder POCUS, a relatively easy skill based on prior studies, but was for considerably harder skills, such as cardiac, lung, and renal POCUS.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Prior research has shown that the learning curve of aorta POCUS is similar to lung and renal POCUS.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e It is notable that in our study, a statistically significant benefit for Peyton\u0026rsquo;s four-step method on aorta POCUS was not noticed, however, there was a trend toward improvement (OR\u0026thinsp;=\u0026thinsp;2.7, LCB\u0026thinsp;=\u0026thinsp;1.0, p\u0026thinsp;=\u0026thinsp;0.058). It is possible that a larger sample would have resulted in a statistically significant finding. This application-specific difference within a singular skill has never been demonstrated before. Educators should prioritize the use of Peyton\u0026rsquo;s four-step method for complex medical skills; however, the two-step method is likely sufficient for relatively simple tasks.\u003c/p\u003e\u003cp\u003eThis research project has several limitations. The small sample size, sampling methods, and study sample (PA students only) limit the generalizability of the findings. However, novice PA students have similar learning curves to other novice medical learners, therefore it would be reasonable to generalize our findings to other novice learners.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Additionally, between assessments, learners may have practiced POCUS skills with individuals taught via the other method and peer-to-peer teaching during these informal practice sessions is likely. It is unclear how this might affect the results of the study. However, given the results, it is unlikely this would have improved the performance of the intervention group and would have more likely diminished the difference between the groups.\u003c/p\u003e\u003cp\u003eGiven these limitations, further studies with larger samples or multiple learner types should be completed to replicate these findings, increasing generalizability. The final skill assessment in this study occurred after a minimum of eight bladder examinations, ten aorta, lung, and renal examinations, and twelve cardiac examinations. Current evidence suggests that, except for bladder POCUS, psychomotor skill levels generally plateau after fifteen or more examinations and guidelines recommend a minimum of twenty-five exams be completed per organ system.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Future research should assess the long-term effect of the use of Peyton\u0026rsquo;s four-step method after additional deliberate practice. Research comparing learning curves between students taught with Peyton\u0026rsquo;s four-step method and the standard, two-step method after completion of the guideline-recommended 25 POCUS examinations, should be considered. Alternatively, performance on a hands-on skills examination, as utilized in this study, could be compared after a prolonged period of deliberate practice, such as at the time of graduation from the PA program.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePeyton\u0026rsquo;s four-step method improves overall psychomotor skill acquisition for POCUS. This is the first study to demonstrate that Peyton\u0026rsquo;s four-step method improves longitudinal performance in the setting of ongoing, deliberate skill practice. Peyton\u0026rsquo;s four-step method specifically improved psychomotor skills in the immediate skill acquisition phase and the delayed skill acquisition phase. The benefit to Peyton\u0026rsquo;s four-step method was noted in more complex POCUS applications, such as cardiac, lung, and renal POCUS; supporting use of Peyton\u0026rsquo;s method to teach complicated procedures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOSPRE; Observed Structured POCUS Readiness Exam\u003c/p\u003e\u003cp\u003ePA; Physician Assistant\u003c/p\u003e\u003cp\u003ePOCUS; Point-of-Care Ultrasound\u003c/p\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: The research proposal was deemed exempt by the Mayo Clinic institutional review board (24-006851) in accordance with the Declaration of Helsinki. Informed consent to participate was obtained after students were notified of the purpose, procedures, risks, benefits, and data storage processes.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not Applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors report no financial and non-financial competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding: Endowment for Educational Research Award from the Mayo Clinic Office of Applied Scholarship and Education Science.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: MB developed the research question and study design, implemented the study, including obtaining IRB approval and securing funding, and wrote the manuscript. RK assisted with study design and learner assessment. DS assisted with statistical analysis and writing of the methods/results sections. JK and CP assisted with the learner assessment. TG, LB, TR, HR, WS, RS, and MI assisted with learner education. DK assisted with study design, IRB development, and mentorship of the primary author. All authors reviewed and edited the manuscript prior to submission.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors would like to acknowledge the Mayo Clinic Office of Applied Scholarship and Education Science. Additionally, they would like to acknowledge Drs. 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GMS J Med Educ 2016 33(4):Doc60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3205/zma001059\u003c/span\u003e\u003cspan address=\"10.3205/zma001059\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGradl-Dietsch G, Hitpa\u0026szlig; L, Gueorguiev B, Nebelung S, Schrading S, Knobe M (2019) Undergraduate Curricular Training in Musculoskeletal Ultrasound by Student Teachers: The Impact of Peyton's Four-Step Approach. Z Orthop Unfall 157(3):270\u0026ndash;278 2019/06//. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/a-0715-2435\u003c/span\u003e\u003cspan address=\"10.1055/a-0715-2435\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGradl-Dietsch G, Menon AK, G\u0026uuml;rsel A et al (2018) Basic echocardiography for undergraduate students: a comparison of different peer-teaching approaches. \u003cem\u003eEur J Trauma Emerg Surg\u003c/em\u003e. /02// 2018;44(1):143\u0026ndash;152. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00068-017-0819-1\u003c/span\u003e\u003cspan address=\"10.1007/s00068-017-0819-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Point-of-Care Ultrasound, POCUS, Bedside Ultrasound, Psychomotor skills, Medical Education, Physician Assistant, competency.","lastPublishedDoi":"10.21203/rs.3.rs-7695150/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7695150/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eMedical education commonly utilizes the \u0026ldquo;see one, do one\u0026rdquo; two-step approach for teaching psychomotor skills; however, recent evidence suggests that Peyton\u0026rsquo;s four-step method leads to superior learning. The effect of Peyton\u0026rsquo;s four-step method on long term skill retention is less apparent and has never been assessed for Point-of-Care Ultrasound (POCUS). The purpose of this research project was to evaluate the effectiveness of Peyton\u0026rsquo;s four-step method on teaching the POCUS psychomotor skills of image acquisition to novice learners. Additionally, this research project assessed the influence of Peyton\u0026rsquo;s four-step method at three different points in time during the skill acquisition phase, in the setting of ongoing deliberate skill practice.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA single-blinded, repeated measures interventional study based on experimental design was completed. PA students from one large academic medical center were randomized into a control group (using the two-step method) and intervention group (using Peyton\u0026rsquo;s four-step method). Students were taught POCUS of the aorta, bladder, heart, lungs, and kidneys. Students' POCUS skills were assessed during the immediate, intermediate, and delayed learning phases. At each assessment, an organ-specific score and a total score were obtained. Scores were compared using a Wilcoxon rank sum test. An ordinal logistic regression analysis was performed using a generalized linear mixed model with a multinomial distribution and cumulative logit link function to assess overall effect of Peyton's four-step method.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eStudents who were taught using Peyton\u0026rsquo;s method were found to have an increased likelihood of higher total scores compared to those taught using usual instruction (OR\u0026thinsp;=\u0026thinsp;4.2, p\u0026thinsp;=\u0026thinsp;0.003). Peyton\u0026rsquo;s method was found to have increased likelihood of higher scores for cardiac (OR\u0026thinsp;=\u0026thinsp;2.3, p\u0026thinsp;=\u0026thinsp;0.032), lung (OR\u0026thinsp;=\u0026thinsp;2.5, p\u0026thinsp;=\u0026thinsp;0.034), and kidney (OR\u0026thinsp;=\u0026thinsp;3.0, p\u0026thinsp;=\u0026thinsp;0.015). Student performance statistically improved with Peyton\u0026rsquo;s four-step method during the immediate (p\u0026thinsp;=\u0026thinsp;0.031) and delayed (p\u0026thinsp;=\u0026thinsp;0.011) skill acquisition phases, but not in the intermediate phase.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003ePeyton\u0026rsquo;s four-step method improves overall psychomotor skill acquisition for POCUS. Peyton\u0026rsquo;s four-step method specifically improved psychomotor skills in the immediate skill acquisition phase and the delayed skill acquisition phase. The benefit of Peyton\u0026rsquo;s four-step method was more prominent in higher complexity POCUS applications.\u003c/p\u003e","manuscriptTitle":"The Effect of Peyton’s Four-Step Method for Teaching Point-of-Care Ultrasound Psychomotor Skills: An Experimental Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 03:41:17","doi":"10.21203/rs.3.rs-7695150/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ae845d6e-6c64-4d8a-b894-8289647a9a70","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:04:50+00:00","versionOfRecord":{"articleIdentity":"rs-7695150","link":"https://doi.org/10.1186/s13089-025-00466-w","journal":{"identity":"the-ultrasound-journal","isVorOnly":false,"title":"The Ultrasound Journal"},"publishedOn":"2025-11-11 15:57:41","publishedOnDateReadable":"November 11th, 2025"},"versionCreatedAt":"2025-10-08 03:41:17","video":"","vorDoi":"10.1186/s13089-025-00466-w","vorDoiUrl":"https://doi.org/10.1186/s13089-025-00466-w","workflowStages":[]},"version":"v1","identity":"rs-7695150","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7695150","identity":"rs-7695150","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}