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 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 4  |  Page : 226-232

Resident comfort teaching and performing pediatric airway procedures after instruction using the Peyton method, standard simulation, or digital platforms

Department of Emergency Medicine, St. Luke's University Hospital and Health Network, Bethlehem, PA, USA

Date of Submission22-Apr-2021
Date of Acceptance06-Sep-2021
Date of Web Publication24-Dec-2021

Correspondence Address:
Dr. Rebecca Jeanmonod
Department of Emergency Medicine, St. Luke's University Hospital and Health Network, Bethlehem, PA
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijam.ijam_51_21

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Introduction: Many learners use the internet or other independent means as a primary way to master procedures. There are also numerous described methods to teach procedures using simulation. The optimal method for teaching procedures is unknown. We compare residents' confidence and performance of pediatric airway skills (bag valve mask [BVM] and endotracheal intubation [ETI]) and their confidence in teaching these skills to others after training using (1) standard simulation (SS), (2) the Peyton method, or (3) self-directed learning.
Materials and Methods: In 2019–2020, emergency medicine (EM) residents at a single program were randomized to one of three training groups. Prior to training, residents underwent standard airway simulation skill assessment sessions with two blinded observers. Residents in the SS group then underwent training using SS with postprocedure debriefing. Residents in the Peyton method group underwent simulation through a structured technique described elsewhere. The residents in the independent learning group were encouraged to master the skills through any means they saw fit. Residents were surveyed regarding prior experience, knowledge base, and confidence in performing and teaching procedures.
Results: Thirty-three residents were randomized. After training, there were no differences between groups in comfort performing procedures. Residents randomized to independent learning were less comfortable teaching ETI than other groups. In 4–6 month follow-up, all residents showed improvement in procedural performance, regardless of assigned learner group.
Conclusions: Residents using self-directed learning to master airway skills are less comfortable teaching ETI than those taught using simulation. Their skill performance is equivalent regardless of teaching method.
The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice.

Keywords: Airway, education, pediatrics, simulation

How to cite this article:
Jeanmonod R, Rammohan G, Grimaldi M, Pester J, Stankewicz H, Patterson R, Minor M, Baker K, Melanson S, Jeanmonod D. Resident comfort teaching and performing pediatric airway procedures after instruction using the Peyton method, standard simulation, or digital platforms. Int J Acad Med 2021;7:226-32

How to cite this URL:
Jeanmonod R, Rammohan G, Grimaldi M, Pester J, Stankewicz H, Patterson R, Minor M, Baker K, Melanson S, Jeanmonod D. Resident comfort teaching and performing pediatric airway procedures after instruction using the Peyton method, standard simulation, or digital platforms. Int J Acad Med [serial online] 2021 [cited 2023 Jun 5];7:226-32. Available from: https://www.ijam-web.org/text.asp?2021/7/4/226/333409

  Introduction Top

Emergency medicine (EM) residencies are expected to prepare physicians for the practice of EM in all its forms, whether community based or academic. Residents are expected to understand the fundamental skills, knowledge, and humanistic qualities that are the foundation of EM.[1] In addition, as part of this residency curriculum, it is required that residents demonstrate competence in teaching different audiences using appropriate strategies based on targeted learning.[1] ACGME requirements state that residents must be able to educate patients, families, students, other residents, and other health-care professionals.[1] Residents' teaching skills are therefore very important; however, most medical schools do not provide this training. It is therefore imperative that residency training programs provide these critical skills. Most institutions, however, have no formal “Resident as Teacher” (RAT) curriculum in place, and there is great variability among those that do.[2]

Beyond simply meeting the ACGME requirements for EM residency programs, training residents to be educators is of practical importance. EM residents, especially senior residents, are expected and relied upon to teach medical students and junior residents in high acuity settings, under significant time pressure. They are also frequently put in situations where they must teach both simple and complex procedures, either in a classroom setting or at the bedside.[3] Even at institutions that have a RAT curriculum, studies have shown that residents lack confidence when teaching, even when learners give them good ratings.[4] There is much less data available specifically addressing teaching residents to teach procedures, however a study from the surgical literature suggests that resident confidence in this setting is also an issue.[5] The optimal method for teaching residents to teach procedures, both simple and complex, is still unknown.

The objective of this study is to determine if the method of teaching a procedural skill to residents has an impact on resident level of confidence with teaching that same skill. We also sought to determine if method of teaching affected performance of skill and retention at 4–6 months. We chose pediatric airway procedures as being adequate to teach both simple (bag valve mask [BVM]) and complex procedures (endotracheal intubation [ETI]). The methods we utilized for teaching these procedures were the Peyton method (a highly regimented procedural teaching method that involves demonstration of a skill by a teacher, deconstruction of the skill by the teacher, demonstration of comprehension by the learner, and finally execution of the task by the learner), standard simulation (orientation to task, skill performance by learner, and debriefing by teacher), and self-driven learning using digital platforms, textbooks, and free access to simulation mannikins.[6]

  Materials and Methods Top

Study design

This was an exploratory three-armed randomized cohort study that assessed optimal teaching of pediatric airway procedures to residents to maximize resident confidence in teaching those procedures to others.

Research quality and ethics statement

The study was reviewed by the IRB and found to be exempt. It was reviewed under protocol SLUHN 2019-60.

Study setting and population

The study was conducted at a community-based level I trauma center that hosts an EM residency program with 12 residents per class. EM residents of all PGY levels (1-3) were included in the study. The study was completed during the 2019–2020 academic year.

Study protocol and measurements

EM residents were randomized to one of three training groups: Peyton method, standard simulation, or self-directed learning. Residents were not immediately informed as to which group they were assigned. Before their training session, all residents underwent a previously validated standardized pre-test (adopted from the ARMY CSC, appendix 1 and appendix 2) using a Laerdel infant simulator model to assess for procedural skills in BVM and ETI. These residents were assessed by a pair of investigators who were blinded to the residents' training assignment and trained in conducting the assessment. Investigators had standardized assessment sheets with narrative cues for scoring residents' performance. These two scores were pooled for each resident.

Residents subsequently underwent training sessions according to their randomization. Residents randomized to Peyton method underwent training by 1 of 3 investigators with experience in the Peyton method. The investigators worked from a standardized script to ensure reproducibility of training sessions. Investigators in these sessions were blinded to the performance of the resident on the pretest. Details regarding the Peyton method are described elsewhere in the literature and not included here for brevity.[6]

Residents randomized to standard simulation were oriented to the goal of the simulation, namely to work through a case of infant respiratory arrest, demonstrating competence in BVM and ETI. Residents then performed the simulation and underwent debriefing by an investigator utilizing the check-list from the pretest to provide feedback for the session.

Residents randomized to self-directed learning were provided with online resources as well as free access to all simulation materials used in the other groups. There were no restrictions placed on where they could get the information they felt they needed to master the skills in this study. They were reminded in person and through E-mail correspondence to complete their training.

Residents completed surveys immediately following their training which assessed the following items: Level of training, number of prior experiences performing the procedures, familiarity with the procedures both before and after their training, comfort with performing the procedures after their training, and comfort with teaching the procedures after their training. This was done in order to assess for differences in groups that preceded randomization that might account for findings. Investigators were blinded to survey responses.

Residents were re-tested 4–6 months after their training session to determine performance and skill retention. Residents were again assessed by two investigators in a standardized fashion, with both investigators blinded to their assigned training groups and pretest performance.

Survey responses regarding level of training and numbers of procedures seen and performed were chosen from a list of closed possibilities to minimize errors in data abstraction. Survey questions regarding comfort with performance and teaching the procedures were graded on a 5-point Likert scale, with 1 representing “not comfortable,” 2 representing “a little bit,” 3 representing “neutral,” 4 representing “pretty comfortable,” and 5 representing “very comfortable.”

Data handling and analysis

Because data were not normally distributed, Kruskal–Wallis was used to compare resident level of training and exposure to procedures in each of the three study arms. Mann − Whitney U-test was used to compare resident comfort with performance and teaching of the procedures before and after training in each study group. Wilcoxon signed-ranks test for repeated measures was used to compare each resident's practical skills test with the same test performed at 4–6 months after the training session. Subgroup analyses were not performed due to small sample size. Because there are not prior data regarding residents' comfort with teaching procedures as a function of the method in which the residents learned the skill themselves, a power calculation could not be undertaken, and this study should be considered exploratory in nature. All data were analyzed using MedCalc (©1993–2013, Ostend, Belgium) and VassarStats.net (©Richard Lowry 1998–2018).

  Results Top

Thirty-three residents were randomized to one of the three study arms. A single resident was unable to complete his training session and was not included in data analysis. Eleven residents were randomized to self-study, nine residents were randomized to standard simulation, and thirteen residents were randomized to Peyton method. Resident assignments and flow diagram are shown in [Figure 1]. Study groups were similar in their levels of training (P = 0.82), prior experience performing pediatric BVM (P = 0.11) and ETI (P = 0.63), and reported familiarity with BVM (P = 0.24) and ETI (P = 0.25). Resident report of prior procedural experience is summarized in [Table 1]. Most residents felt somewhat familiar with indications, contraindications, and complications of BVM and ETI, with a median score of 4 (IQR 3–4) and 4 (IQR 2.5–4) on a 5-point Likert scale, respectively.
Figure 1: Flow diagram of resident assignments and follow-up

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Table 1: Resident report of prior experience with observation and performance of pediatric airway procedures

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Skill performance on pretest of BVM was similar between groups (P = 0.69), with a median score of 7 on a 10 point scale (IQR 6–8). The most common areas of deficiency were preparing suction prior to procedure and ventilating the infant mannikin at an appropriate respiratory rate. Skill performance of ETI on pretest was also similar among groups (P = 0.9), with a median of 6 on a 10 point scale (IQR 4–8). Common areas of deficiency included preparation and checking of equipment before intubation, particularly suction, placing the endotracheal tube to the appropriate depth, and appropriately securing of the tube.

After training, there were no differences in resident comfort performing either BVM or ETI independently (P = 0.65 and P = 0.44, respectively). Resident comfort in performing procedures independently is demonstrated in [Table 2]. Residents in all three groups expressed similar comfort in teaching BVM to another person, [P = 0.53, [Figure 2]]. Residents who were randomized to self-directed learning were less comfortable in teaching ETI compared to residents randomized to other learner groups [P = 0.03, [Figure 3]].
Table 2: Resident comfort with performance of pediatric procedures without supervision

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Figure 2: Resident comfort teaching pediatric bag valve mask according to training assignment (P = 0.53)

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Figure 3: Resident comfort with teaching endotracheal intubation according to training assignment (P = 0.03)

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Twenty-five residents were able to be reassessed regarding their skills retention at 4–6 months. The remaining 7 could not be followed up within the time frame due to social distancing guidance from the IRB related to the SARS-CoV-2 pandemic. Ten of these residents were in the Peyton method group, 7 were in the standardized simulation group, and 8 were in the self-directed learning group. There were no intergroup differences in BVM or ETI skill performance at follow-up testing (P = 0.85 and P = 0.20, respectively). On the whole, residents showed significant improvement in their BVM skills over time with a median score of 9 (IQR 8–9, P = 0.047, Wilcoxon signed-ranks test). Residents also showed significant improvement on retesting in their ETI skills at 4–6 months, with a median score of 8 (IQR 8–9, P = 0.001 by Wilcoxon signed-ranks test).

  Discussion Top

There are many challenges to procedural teaching, both from the point of view of the teacher and the learner. For the teacher, teaching a procedure at the bedside in real time can be limited by patient acuity and volume, ethical factors (such as not having underqualified individuals “practice” on patients), and the number of patients that actually require the procedure. Uncommon procedures may simply not occur with a frequency that is sufficient to adequately teach a learner. Furthermore, given shift variability in EM, it is unlikely that a given teacher will be able to adequately assess a learner's procedural skills on the sole basis of clinical practice to develop a level of comfort with allowing that learner independence. For learners, this often translates to limited hands-on procedural experience or procedures which have been observed, but not performed. Therefore, alternative learning opportunities must be sought.

There is no ideal substitute to procedural experience with live patients. Medical simulation has experienced significant advancements since it was first introduced to the field of medicine in the 1980s and has become an integral component of medical education, offering residents the ability to experience realistic patient encounters in a controlled environment with proscribed learning objectives.[7] Simulation offers customizable experiences and repetition to ensure learner objectives and critical actions are met. When combined with debrief sessions, simulation offers residents the ability to focus on knowledge gaps and master core concepts and procedures without patient safety risk. However, simulators lack the feel of real life, and the learning experience is highly dependent on the quality of the debriefing afterward.

The Peyton method, described by Peyton in '98 in surgical medical education, seeks to promote procedural competence by standardizing procedural teaching, breaking down complex tasks in a stepwise manner to facilitate comprehension and reproducibility of performance.[6] The method entails the teacher performing the procedure once (demonstration). Then, the teacher performs the procedure a second time, slowly, verbally explaining each step (deconstruction). The teacher then performs the procedure a third time at the direction of the learner (comprehension). Finally, the learner performs the procedure (execution). This method, which requires less spontaneous decision making on the part of the learner than standard simulation and less cognitive burden on the teacher (as this method is largely scripted), focuses strongly on the mechanics of procedural performance. It has been shown to be superior to other methods of teaching in complex procedures but has not shown any benefit in less complex procedures.[8],[9],[10],[11]

Online resources for medical education also offer alternatives to learning procedures and have exploded in number and popularity since the early 2000s.[12] In particular, free open-access medical education (FOAM) has occupied an increasingly important position in the education of EM residents.[13],[14] Often disseminated with the help of various social media platforms, FOAM resources such as e-books, wikis, blogs, and podcasts are readily available and used by residents for acquiring general medical knowledge as well as procedural skills.[12],[13],[14],[15] These resources have the benefit of increased accessibility, being able to be accessed asynchronously by the learner. Such resources may increase exposure to the primary literature and improve familiarity with relatively less common procedures.[13],[14] However, appropriate concerns have been raised regarding the lack of coverage of certain content areas as well as broader questions related to the reliability and quality of online content.[16],[17] In response, many online resources have started to incorporate versions of peer review but concerns remain surrounding their reliability.[18] Online learning is also highly dependent on the learner's insight into his or her own knowledge gaps and subject to the learner's work ethic and motivation.

In our study, those who were assigned to the self-directed learning group felt less comfortable teaching ETI compared to those in either the Peyton method group or the standard simulation group. However, there were no differences with regard to comfort level for teaching BVM ventilation. We speculate this difference can be attributed to multiple factors. First, increased psychomotor complexity involved with pediatric ETI may make learners feel less secure with their ability to independently master the task to a point of comfort with teaching the skill themselves. Multiple pieces of uniquely sized equipment are required, and there are more steps involved with ETI compared to BVM ventilation. Teaching a skill requires a level of mastery beyond that of performance, and it is possible that independent learners, although not inferior in skill performance, lacked true mastery of the material. Second, pediatric ETI is a relatively rare event outside of the operating room; therefore, residents have less real-life experience from which to draw. BVM occurs more commonly; therefore, residents may have felt more familiar with the procedure in general outside of the study experience. Third, it is possible that BVM ventilation is perceived as less critical compared to ETI. Residents may feel more comfortable teaching a skill which they feel has more room for error, or a skill they perceive as less important or less difficult.

In addition, our study may demonstrate that comfort in teaching a skill may be enhanced by interacting with an actual teacher, which is absent in self-directed learning. Self-directed learning, by definition, takes place by one's self, and traditional teaching methods generally involve a dyad or group dynamic that is lacking in most digital platforms. It is possible that comfort in teaching was partly augmented by the learner modeling the actual teaching that occurred, and not merely the acquisition of the skill set by the learner. In other words, the learner learned the procedure, but also learned teaching skills in the process of being taught. Engaged learning with an experienced instructor is likely to have nuance not present in self-directed learning, allowing learners to incorporate environmental and nonverbal cues as well as interactive and organizational skills important in teaching.

In our study, no difference was seen in residents' skill retention 4–6 months after training in any of the three study groups and so this study failed to show superiority of any of the instructional methods utilized (Peyton, standard simulation, or self-directed learning). This is an interesting finding given that one of the methods (self-directed learning) requires significantly less instructor time than the other 2 approaches. Neither of the procedures utilized in this study (pediatric BVM or pediatric intubation) were novel procedures for any of the residents. EM residents learn these procedures during medical school, and while they may not have been proficient, they had likely received some foundational training in these procedures prior to the current study. The impact of the procedural training method used in the study may have had a larger impact had the procedure been completely new to them. Residents are motivated, adult learners with decades of experience in mastering new knowledge and skills. The success seen in skill retention in the self-directed learners suggests that such learners may need no more than a reminder of the importance of knowing a procedure to achieve the same success as those actually trained by instructors.


This study was performed at a single EM residency training institution which would best be described as a hybrid academic-community site. It is possible that certain characteristics of residents, including learning style, who preferably match at such a site are different than those of residents who tend to match at county or large academic institutions, and so our results are not necessarily generalizable. Because our study was limited to the residents in our training program, our overall sample size was relatively small which could have affected the ability to detect statistically significant differences between the groups. Due to the nature of the study, participants were not able to be blinded as to which group they were assigned to. This may have led to response bias, where subjects in the Peyton method and standard simulation groups would have been inclined to feel they should report more comfort with teaching, whereas subjects in the self-directed learning group might have felt that they were supposed to report feeling less comfortable. In addition, we did not make any attempt to limit access to either simulation dolls or instructor time for any learner. During the 4–6 month follow-up time period, learners may have gained variable experience with pediatric airway techniques, and all had access to their faculty (including scheduled anesthesia, pediatric intensive care unit, neonatal intensive care unit, or simulation electives) and unlimited access to online resources to use as they saw fit. Therefore, the effects of the assigned group may have been washed out in the preceding months through other forms of experiential learning.

  Conclusions Top

Our study demonstrated that there was no difference in EM residents' ability to improve in the simple and complex procedural tasks of pediatric BVM use and ETI regardless of the teaching method used to teach them. Residents improved procedural proficiency with teaching and time. Residents' comfort in teaching these procedures to others was better in the two groups that had in-person instruction (simulation and Peyton method) than in the group that was randomized to asynchronous self-directed learning.

Financial support and sponsorship


Conflicts of interest

Dr. Rebecca Jeanmonod is a member of the IJAM Editorial Board. Appropriate procedures to minimize any actual or perceived conflic of interest were followed during the peer review process.

Research quality and ethics statement

The study was reviewed by the St. Luke's University Health Network Institutional Review Board and found to be exempt. It was reviewed under protocol number SLUHN 2019-60. In addition, the authors attest that pertinent EQUATOR Network guidelines were followed.

  References Top

ACGME Program Requirements for Graduate Medical Education in Emergency Medicine; July 2019. Available from: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/110_EmergencyMedicine_2019.pdf?ver=2019-06-25-082649-063. [Last accessed on 2021 May 06].  Back to cited text no. 1
Messman A, Kryzaniak SM, Alden S, Pasirstein MJ, Chan TM. Recommendations for the development and implementation of a residents as teachers curriculum. Cureus 2018;10:e3053.  Back to cited text no. 2
Walsh R, Bass J, Gorbatkin C, Bothwell J. 52 procedures in 52 weeks: An innovative curriculum for emergency medicine residents. West J Emerg Med 2017;18:12-3.  Back to cited text no. 3
Spada M, Lundblad W, Glance J, Rosenstock J, Gopalan P, Azzam PN, et al. Self-assessment of teaching skills among psychiatric residents. Acad Psychiatry 2018;42:477-81.  Back to cited text no. 4
Anderson MJ, Ofshteyn A, Miller M, Ammori J, Steinhagen E. “Residents as teachers” workshop improves knowledge, confidence, and feedback skills for general surgery residents. J Surg Educ 2020;77:757-64.  Back to cited text no. 5
Peyton JW. Teaching in the theatre. In: Peyton JW, editor. Teaching and Learning in Medical Practice. New York: Manticore Europe; 1998. p. 171-80.  Back to cited text no. 6
Heitz C, Ten Eyck R, Smith M. Simulation in medical student education: Survey of clerkship directors in emergency medicine. West J Emerg Med 2011;12:461-6.  Back to cited text no. 7
Romero P, Gunther P, Kowalewski KF, Friedrich M, Schmidt MW, Trent SM et al. Halsted's “see one, do one, and teach one” versus Peyton's four-step approach: a randomized trial for training laparoscopic suturing and knot tying. j surg educ. 2018;75:510-15.  Back to cited text no. 8
Balafoutas D, Joukhadar R, Kiesel M, Häusler S, Loeb S, Woeckel A, et al. The role of deconstructive teaching in the training of laparoscopy. JSLS 2019;23:e2019.00020.  Back to cited text no. 9
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Gradl-Dietsch G, Lubke C, Horst K, Simon M, Modabber A, Sönmez TT, et al. Peyton's four-step approach for teaching complex spinal manipulation techniques – A prospective randomized trial. BMC Med Educ 2016;16:284.  Back to cited text no. 11
Cadogan M, Thoma B, Chan TM, Lin M. Free Open Access Meducation (FOAM): The rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J 2014;31:e76-7.  Back to cited text no. 12
Purdy E, Thoma B, Bednarczyk J, Migneault D, Sherbino J. The use of free online educational resources by Canadian emergency medicine residents and program directors. CJEM 2015;17:101-6.  Back to cited text no. 13
Mallin M, Schlein S, Doctor S, Stroud S, Dawson M, Fix M. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med 2014;89:598-601.  Back to cited text no. 14
Chan T, Dzara K, Dimeo S, Bhalerao A, Maggio L. Social media in knowledge translation and education for physicians and trainees: A scoping review. Perspect Med Educ 2020;9:20-30.  Back to cited text no. 15
Munz N, Chen EH. Embracing FOAM as an academic community. AEM Educ Train 2019;3:396-7.  Back to cited text no. 16
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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