Assessing the Impact of Peyton’s Teaching Method on Acquisition of Clinical Skills Among ENT Interns: A Prospective Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This prospective single-center study evaluates whether Peyton’s Four-Step Approach improves acquisition of core ENT skills among interns compared with conventional faculty demonstration. Fifty interns were randomized to either method and trained in anterior rhinoscopy, Trotter’s method, and anterior nasal packing, with immediate performance assessed via validated OSCE checklists and learner perceptions captured through Likert-scale questionnaires. The authors report significantly higher OSCE scores in the Peyton group for the more complex procedures (Trotter’s method and nasal packing), while no difference emerged for the simpler diagnostic task of anterior rhinoscopy. Learners also rated Peyton’s approach more favorably for memory retention and transferability to other skills, suggesting added cognitive and motivational benefits for procedural learning in ENT.

Methodologically, strengths include random allocation, use of standardized OSCE tools, and combined objective and subjective outcomes. However, the small sample size, single-center design, and assessment limited to immediate post-training performance constrain generalizability and preclude conclusions about long-term retention. Potential instructor effects remain, as different faculty taught each arm despite similar training. Reporting effect sizes and confidence intervals would strengthen interpretation beyond p-values, and clearer justification of the ≥75% “good performance” threshold is warranted. The discussion situates findings within broader procedural education literature, but the manuscript would benefit from citing key ENT-specific and skills-lab training work by the Lechner/Sharaf group and by Weimer et al., who have contributed foundational evidence on structured skill acquisition, simulation-based curricula, and learner-centered procedural training in otolaryngology. Incorporating these references would better anchor the study within established ENT education research and clarify how Peyton’s method aligns with or extends existing competency-based frameworks. Overall, the study offers pragmatic support for structured, stepwise teaching in moderately complex ENT procedures, while highlighting the need for multicenter, longitudinal trials assessing durability, scalability, and cost-effectiveness.

Author Response

We thank the reviewer for their insightful and detailed assessment.

Comment on effect sizes and confidence intervals: We have now added the standardized mean difference (Cohen’s d) with 95% confidence intervals to the Results section (Section 3.2) and Table 3. The interpretation of these effect sizes has been integrated into the narrative.

Comment on justification of the ‘good performance’ threshold: We have added a sentence in the Methods (Section 2.5) clarifying that the ≥75% threshold was determined “by consensus among the researchers based on curricular standards.”

Comment on citing key ENT-specific literature: We have significantly expanded the discussion (new subsection 4.3, “Comparison with similar research in Otorhinolaryngology”) to incorporate and discuss relevant work by the Lechner/Sharaf group (references 15-17) and Weimer et al. (reference 18), situating our findings within the context of established ENT education research.

Comment on long-term retention and generalizability: We have explicitly acknowledged these as limitations in the Discussion (Section 4.4), stating: “On the flip side, it was done at just one center with a relatively small group of interns, only looked at immediate results rather than long-term skill retention, and didn't test how skills held up over time.”

Reviewer 2 Report

Comments and Suggestions for Authors

The results are well presented and consistent with previously published evidence, particularly in showing the advantage of Peyton’s method for more technically demanding skills

Author Response

We thank the reviewer for their positive feedback on the clarity and consistency of our results with existing evidence.

Reviewer 3 Report

Comments and Suggestions for Authors

While the topic is relevant and timely, the Peyton approach should be described and analyzed in greater detail to allow reproducibility by other educators and researchers. The same applies to the OSCE questionnaire. These details should be provided either within the main manuscript or as a supplementary file, clearly outlining all aspects of the educational practice and assessment tools used.

I also have three minor comments:

1. The manuscript would benefit from a more detailed discussion of the traditional or conventional demonstration techniques. Specifically, it is unclear whether the lower impact observed is truly attributable to the superiority of Peyton’s method or to limitations in how the traditional technique was implemented. I believe at least a comment on this is needed.

2. A comparison on the time needed for each method would be of use

3. It would strengthen the manuscript to include additional potential examples illustrating the application of Peyton’s method in otolaryngology, which would enhance its practical relevance for readers in this specialty.

Author Response

We thank the reviewer for their valuable suggestions to enhance the methodological clarity and practical relevance of our manuscript.

Comment on detailed description of Peyton’s approach and the OSCE: We have substantially expanded the description of Peyton’s Four-Step Approach in the Introduction, breaking it down into its core, reproducible objectives and steps. The detailed OSCE checklists and the structured breakdown of the Peyton’s method intervention are provided as supplementary files to ensure full reproducibility.

Minor Comment 1 (Implementation of the traditional method): We have added a paragraph in the Introduction explicitly describing the conventional apprenticeship-style model used for teaching the three ENT procedures. Furthermore, we have added a nuanced point in the Limitations (Section 4.4): “Also, another limitation of this study is the difficulty in determining whether the outcomes are attributable to the core principles of Peyton’s method or to potential inconsistencies in how the conventional teaching approach was delivered.”

Minor Comment 2 (Time comparison): We have added a new table (Table 2) in the Results (Section 3.1) detailing the time taken to teach each skill using both methods, along with a corresponding sentence in the narrative: “Peyton's method took almost double the time to teach when compared to the traditional method as seen in Table 2.”

Minor Comment 3 (Additional ENT examples): We have enhanced the Discussion (Section 4.3) by citing a recent study (reference 19) that successfully applied a modified Peyton’s approach to teaching thyroid and cervical lymph node ultrasound zoning, illustrating the method’s adaptability to related diagnostic skills in otolaryngology.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you. The revision has improved the manuscript and met the aforementioned comments.

Author Response

Thank you for the kind words of appreciation.

Reviewer 3 Report

Comments and Suggestions for Authors

dear authors 

thank you for your efforts and your kindness to address my suggestions

Please discuss in more details the differences  between Peyton's Teaching Method and the conventional teaching method (have you used all the steps and in what way these stapes are different to the "classical" training method in your specific examples)

 

Author Response

Dear Reviewer,

Thank you for your thoughtful and constructive feedback on our manuscript. We agree that a more detailed, side-by-side comparison of the two teaching methods strengthens the paper by clarifying the exact nature of the intervention.

In direct response to your comment, we have revised the manuscript to include a detailed, step-by-step breakdown of how Peyton's Four-Step Approach was implemented in contrast to the conventional demonstration method. Specifically, we have:

1. Expanded the "Intervention" subsection (Section 2.3): We have added explanatory text that explicitly describes the core, reproducible elements of Peyton's method as delivered in our study (e.g., silent first demonstration, learner verbalization in Step 3, etc.).

2. Updated the Discussion: We have integrated this operational detail into the interpretation of our results, linking the structural differences between the methods to the observed outcomes for the more complex skills.

Also, we have added a new comparative table as Supplementary File: This table provides a phase-by-phase procedural contrast of both methods for teaching "Anterior Nasal Packing," illustrating the distinct activities for the instructor and learner in each step.

We believe these additions provide the precise, procedural clarity you requested and hope the revised manuscript now fully addresses your valuable point.

Thank you again for your time and expertise.