The four-stage approach to teaching skills

Instructors and graduates of certain Life Support courses will be familiar with the ‘four stage’ approach to teaching procedural skills (demonstration, deconstruction, formulation, performance):

  1. Silent run through in which teacher performs without commentary;
  2. teacher then performs while commentating;
  3. teacher then performs with commentary from student(s);
  4. finally student performs and commentates.

Two randomised studies published this month showed no improvement in skills performance with this teaching method compared with simpler approaches. One involved needle cricothyroidotomy1 and another laryngeal mask insertion2.
An accompanying editorial3 acknowledges that this might put an end to this educational dogma, but one should consider that the procedures taught in these studies were simple to perform, and the results might not be extendable to more complex procedures.
The editorial points out there are some interesting data describing the neurophysiological basis of learning. Observing actions made by others activates the cortical circuits responsible for the planning and execution of those same actions; this visual-motor coupling happens through a neuronal matching network called the Mirror Neuron System (MNS). Listening to a verbal description of a skill can activate the same visual-motor circuit as those activated by the hand or the leg when completing the skill. Even during new motor pattern formation there is significant NMS activation, supporting the concept that the building of motor memories is based on the combination of observation and execution.
The ingredients of the complex mechanism of motor learning are observation, listening and immediate execution. The priority that should be given to each of the individual components of motor skills teaching is difficult to quantify and should be the subject of future research.
The editorialists conclude: The four-stage approach has been used for years with no evidence of better skill acquisition and retention compared with traditional methods. Medical educators need high-quality data to address the knowledge gaps for this topic and the two studies in this issue have set a precedent for future research. In our opinion, we should continue to use the four-stage approach to skill teaching while waiting for more evidence of a superior approach.
I differ slightly in my conclusion: if I have a limited time to teach a skill station (like airway management in the APLS course), I know I’m a little more justified in ditching this time consuming ritual in favour of more hands-on time for the paying delegates.
1. Emergency skill training—A randomized controlled study on the effectiveness of the 4-stage approach compared to traditional clinical teaching
Resuscitation. 2010 Dec;81(12):1692-7
2. A randomised trial comparing a 4-stage to 2-stage teaching technique for laryngeal mask insertion
Resuscitation. 2010 Dec;81(12):1687-91
3. The four-stage approach to teaching skills: The end of a dogma?
Resuscitation. 2010 Dec;81(12):1607-8
Neurologist Vilayanur Ramachandran explains the mirror neuron system in this video from

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