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”

For centuries, the way surgeons learned their craft was a simple, direct transfer of knowledge from master to apprentice. A student would watch a procedure, then immediately try it themselves, learning through observation and immediate repetition. This traditional method, often summarized as "see one, do one," relied on the idea that watching an expert perform a task once was enough preparation to attempt it. However, as medical training has moved into modern classrooms and simulation labs, educators have begun to question whether this rapid-fire approach truly helps students retain complex skills over time. A newer method has emerged to challenge the old way, one that breaks a procedure down into smaller, manageable pieces and requires the student to explain the steps back to the teacher before ever touching the tools. This structured approach, known as Peyton's Four-Step Method, asks learners to engage their minds deeply with the sequence of actions, turning passive watching into active understanding. The question facing medical schools today is whether this extra mental effort translates into better long-term results, or if the traditional, faster route remains sufficient for teaching the basics of surgery.

In a recent study conducted at a medical school in Karachi, Pakistan, researchers set out to test these two teaching styles head-on. They gathered fifty undergraduate medical students who had never before handled surgical instruments or practiced basic procedures. The students were divided into two equal groups. One group was taught using the traditional "see one, do one" method, where an instructor demonstrated a skill once, and the student then practiced it on their own. The other group was taught using Peyton's Four-Step Approach. In this structured version, the instructor first performed the task at normal speed without speaking. Then, they performed it again, this time explaining every single step in detail. Next, the student described the steps aloud while the instructor followed their verbal instructions. Finally, the student performed the task independently. The students in both groups practiced four fundamental skills: putting on sterile gloves, making a surgical incision, stitching a wound with interrupted sutures, and tying a one-handed knot.

The researchers did not stop there. To see which method actually helped students remember what they learned, they waited three months before asking the students to return and perform the same tasks again. Independent experts, who did not know which teaching method each student had received, watched video recordings of the students performing the skills and scored them on a scale from unsatisfactory to perfect. The results were clear and consistent. The students who had learned through the structured, four-step method performed significantly better across all four skills than those who had learned through the traditional method. When looking at the overall score combining all four tasks, the group taught with Peyton's approach had a median score of 17, while the traditional group scored a median of 12. This difference held true regardless of whether the students were in their early years of medical school or their later years, and it applied equally to both male and female students.

The study also measured how long it took to teach each skill. The structured method required more time. For example, teaching a student how to tie a knot took a median of 106 seconds with the four-step method, compared to just 57 seconds with the traditional method. Similarly, learning to suture a wound took 314 seconds with the structured approach versus 153 seconds with the traditional approach. Despite this extra time investment, the students who spent more time in the classroom with the structured method retained their skills much better three months later. The researchers noted that the traditional method was faster to deliver, but it did not lead to the same level of long-term retention. The findings suggest that taking the time to break down a task, explain it, and have the student verbalize the process creates a stronger memory of the skill, even if it takes longer to teach in the moment.

The authors of the study concluded that while the traditional "see one, do one" method is efficient, it may not be the best way to ensure students remember how to perform basic surgical skills weeks or months later. The structured, step-by-step approach, which forces the student to think through the procedure and explain it, appears to build a more durable foundation of knowledge. The study did not find that gender or the student's year of study changed the outcome; the structured method worked better for everyone. While the researchers acknowledged that their study was limited to a single institution and a small number of students, the results point toward a shift in how basic surgical skills might be taught. Rather than rushing through a demonstration, educators might benefit from slowing down, breaking tasks into parts, and ensuring the student can articulate the process before they are allowed to perform it. This approach prioritizes deep understanding over speed, suggesting that in the high-stakes world of surgery, the time spent learning carefully may be the most valuable time of all.