One the most exciting and important developments in surgical education and practice is the growing adoption of psychological performance enhancement skills to complement motor proficiency. Being adapted from other High Expectation and Risk Occupations (HERO) like special forces, policing, firefighting and athletics, this mindset and these techniques have the potential to augment every surgeon’s performance. Under the rubric of SIM -the Surgeon’s Imagery Mindset- this guide presents an essential understanding of the most frequently applied mental skills technique utilized by surgeons, commonly referred to as mental imagery, mental practice and/or mental rehearsal. Now termed PEMIs -Performance-Enhancing Mental Imagery for Surgeons- the technique, its applications, keys to effectiveness and model examples are provided here to help surgeons master this powerful performance synergist, no matter their stage of professional development. SIM is the conduit from the “mind’s eye” to the surgeon’s hand... and the patient’s well-being.