Guest Author: Shimae Fitzgibbons, MD, Med, Senior Associate Dean for Evaluation and Assessment, GUSOM, Associate Professor, MGUH, Department of Surgery

Bedside procedural teaching can pose unique challenges, including time constraints and high-stakes environments for delivering education. You cannot pause during a bedside procedure to look something up, reflect on the situation, consult the literature on standards of care, and then return to the patient. Educators, meanwhile, have more to juggle. Care must be taken not only to provide a rich educational experience but also to keep the patient safe and ensure a successful procedural outcome. 

In this high-stakes bedside environment, teaching often invokes images of letting the learner “do” the procedure. We might imagine shaky-handed novices slowly advancing guide wires and catheters under the watchful gaze of an attending. I would like to offer an alternative educational scenario. I would like us to reconsider the bedside educational experience and broaden our understanding of what might be valuable to the novice proceduralist.

Walker and Peyton outline a four-step approach to bedside procedural teaching. This thoughtfully described framework invites us to transform complex clinical procedures into manageable learning experiences. The evidence-based methodology uses a structured progression that builds competency. It addresses the challenge of cognitive load inherent in procedural learning and allows trainees to develop both technical skills and clinical reasoning in a safe, supervised environment.

The Walker-Peyton model consists of four distinct phases:

Step 1: Demonstration. The instructor performs the entire procedure at normal speed and without interruption while the learner observes, gaining an overview of the complete task.

Step 2: Deconstruction. The instructor repeats the procedure while providing detailed commentary about each action, explaining the rationale, technique, and potential pitfalls. This verbal breakdown helps trainees understand not just what is being done, but why each step is important.

Step 3: Comprehension. While the instructor performs the procedure, the trainee talks through each step, allowing the instructor to assess understanding and correct misconceptions. This verbal rehearsal identifies knowledge gaps and builds confidence before performing the actual procedure.

Step 4: Performance. The trainee executes the procedure under close supervision, with the instructor providing real-time guidance and feedback.

The four-step approach maximizes learning efficiency while prioritizing patient safety. This model provides multiple touchpoints for assessment and feedback well before independent performance. By intentionally prefacing motor skills performance with a demonstration of cognitive understanding, this approach facilitates the graduated procedural autonomy required to build competent and confident practitioners.

Article reference:

Walker M, Peyton JWR. Teaching in theatre. In: Peyton JWR, editor. Teaching and learning in medical practice. Rickmansworth: Manticore Europe Limited; 1998. p. 171–80.

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