Journal of Surgical Education - Articles in Press

Does Success on the American Board of Surgery General Surgery Qualifying Examination Guarantee Certifying Examination Success? - Corrected Proof

Thomas W. Biester, Jonathan D. Rubright, Andrew T. Jones, Mark A. Malangoni — 2012-05-14

Objective: The purpose of this study was to explore the relationship between qualifying examination (QE) and certifying examination (CE) results and to determine whether an appropriate cut-point on the QE would predict success on the CE. Design: The scaled American Board of Surgery (ABS) QE scores of all first-time examinees from 2006 to 2010 were retrospectively matched to their first-time CE pass/fail decisions. Contingency tables illustrating the QE–CE relationship were constructed and appropriate correlational statistics were computed. A receiver operating characteristic (ROC) curve analysis was constructed, with sensitivity and 1-specificity calculated for each possible QE cut-point used to predicted CE pass/fail classifications. Additionally, the area under the curve (AUC) was calculated. Participants: All first-time American Board of Surgery examinees for the Surgery Qualifying Examination from 2006 to 2010. Results: A total of 4385 surgeons were analyzed, with QE scores averaging 82.1 ± 5.8 (range, 58-99) and 82.8% of surgeons passing the CE on their first attempt. Contingency tables suggest a moderate relationship between QE and CE performance, although correlation indexes are low (phi = 0.13, point-biserial = 0.23). For the ROC analysis, the AUC = 0.674 (95% CI; 0.654-0.695) provides a better than chance pass/fail classification (p < 0.001), yet does not meet the minimum threshold for acceptability as a predictive test. No QE cut-point accurately predicted CE pass/fail decisions. Conclusions: While a moderate relationship between QE scores and CE performance is evident, correlations suggest that the 2 examinations measure different abilities. The low AUC value on the ROC analysis, along with poor predictability at all possible cut-points, show that no appropriate cut-point on the QE predicts success on the CE. These data add to the validity of both tests by providing evidence that distinct latent traits are being measured by both tests.

Trends in Urology Resident Exposure to Minimally Invasive Surgery for Index Procedures: A Tale of Two Countries - Corrected Proof

2012-05-11

Objective: To interrogate case-log data for American and Canadian urology residents to define trends in minimally invasive surgery (MIS) and open surgery and compare operative experiences between these 2 groups. Methods: Case-log data from 2004 to 2009 for American urology residents was compared with Canadian residents for 8 index cases, which are routinely performed in both an MIS and open approach. These included nephrectomy (donor, radical, simple, partial), prostatectomy (radical), adrenalectomy, pyeloplasty, and nephroureterectomy. Results: Linear regression analysis demonstrated a significant increase in the percentage of MIS radical prostatectomies performed by American residents (11.2%–52%), compared with Canadian residents (0.74%–11.2%). There was also a significant increase in the percentage of MIS donor nephrectomies by Canadian residents (5.6%–68.7%), compared with American residents (70.1%–89.1%). For Canadian residents, exposure to the following 3 MIS procedures increased significantly over open approaches: adrenalectomy, radical prostatectomy, and donor nephrectomy. For American residents, all index procedures with the exception of adrenalectomy underwent a significant increasing trend (all p < 0.05). Conclusions: Trends for 8 index procedures confirm a continuing shift towards MIS for the majority of procedures in both countries. Differences may be only temporal and relate to dissimilar health care delivery models with a resultant lag in the adoption of laparoscopy and robotics in Canada. The impact of these trends upon ultimate surgical competence of graduates remains to be seen.

The Utility of the ABS In-Training Examination (ABSITE) Score Forms: Percent Correct and Percentile Score in the Assessment of Surgical Residents - Corrected Proof

Deepa Taggarshe, Vijay Mittal — 2012-05-11

Objective: The American Board of Surgery (ABS) provides program directors with ABS In-Training Examination (ABSITE) scores in the following forms: Percent correct score and percentile score. It is of interest to note how residency programs utilize the different forms of ABSITE scores in assessment of surgical residents for progression in training. We conducted a survey of program directors to ascertain the present situation. Methods: A structured questionnaire was sent to all program director members of the Association of Program Directors in Surgery. Results: 114/210 program directors (54%) answered the survey. To assess residents, 3 programs used only the percentage correct score, 23 programs used only the percentile score, and 88 programs used both scores. The majority (70/89 or 79%) of the programs used a 30th percentile score as the minimum passing score. 88/111 (79%) programs had a remedial process for residents with poor performance on ABSITE. 60 percent of the programs had never used poor ABSITE performance to defer individual resident promotion. Programs that used ABSITE performance for remediation and deferral of promotion did it based on percentile score rather than percent correct score. Program directors felt that the better indicator of a resident's knowledge and progression in surgical residency was percent correct score (42%) vs percentile score (32%), while 10% felt that neither was an adequate indicator. Conclusions: ABSITE score is being used as one of the measures to assess residents. Programs need to ensure that an effective remedial process is in place to assist residents with poor performance.

Training of Surgical Endoscopists in Korea: Assessment of the Learning Curve Using a Cumulative Sum Model - Corrected Proof

Han Hong Lee, Kyo Young Song, Cho Hyun Park, Hae Myung Jeon — 2012-05-07

Objective: Surgeons' interest and participation in endoscopy have increased recently. The aims of the present study were to assess the learning curve for surgical training in upper endoscopy and to suggest an appropriate training program for surgeons in Korea. Design: Under the supervision of skilled endoscopists, 4 trainees who participated in this study performed more than 150 esophagogastroduodenoscopy procedures, according to the recommendations of the American Society for Gastrointestinal Endoscopy. The success of the procedures was defined as the fulfillment of designated time and checkpoints. A cumulative sum model was used to assess the learning curve. Results: During the same period, the 4 trainees completed 158, 160, 166, and 180 procedures, respectively. Plateau points occurred on the learning curve at the 81st, 90th, 98th, and 111th case in the cumulative sum model and the mean value of the plateau was the 95th case. Conclusions: An intensive education tool and training module that meets the conditions of surgical residents is mandatory for the training of proficient surgical endoscopists.

Can Residents Safely and Efficiently be Taught Single Incision Laparoscopic Cholecystectomy? - Corrected Proof

Mark Joseph, Michael Phillips, Timothy M. Farrell, Christopher C. Rupp — 2012-05-07

Objective: Single incision laparoscopic cholecystectomy (SILC) has recently emerged as an option for selected patients undergoing gallbladder removal. While SILC appears safe when performed by experienced surgeons under controlled conditions, there are no studies evaluating the SILC learning curve for incorporation into resident education and the effect on OR efficiency. Design, Setting, and Participants: Chief residents were taught and evaluated by a single attending surgeon facile with SILC techniques. Residents were transitioned from assistants to primary surgeon during their clinical rotation. Outcomes data were prospectively tabulated compared with data from standard laparoscopic SLC and attending surgeon SILC outcomes. The setting was an academic, tertiary care teaching hospital. Participants were chief residents rotating on hepatobiliary surgery service. Residents previously had demonstrated mastery of basic laparoscopic surgical techniques. Results: Seven chief residents were evaluated with a total of 49 SILCs with a mean of 7 (range 5-12) SILCS/resident. Five conversions to SLC occurred, all within the first 3 SILCs performed by the resident as operative surgeon. Mean blood loss was 30 mL. Median length of stay was <1 day. Average length of operation increased after the first 2 cases, reflecting the transition of the attending surgeon from primary surgeon to assistant role. By the fifth case, operative times returned to the attending surgeon SILC baseline and historical operative times for SLC at our institution. Factors associated with longer-length of surgery were increasing BMI and presence of acute or chronic cholecystitis, choledocholithiasis, and use of intraoperative cholangiogram. Five postoperative complications occurred and were not associated with position along the resident's learning curve. One death occurred due to metastatic laryngeal cancer within 30 days of SILC. Conclusions: Residents can safely be taught the techniques of SILC with minimal disruption to operating room efficiency. Residents already proficient in the use of standard laparoscopic techniques transition to SILC quickly with a short learning curve and proper instruction.

Impact of Implementation of a Pediatric Surgery Fellowship on General Surgery Resident Operative Volume - Corrected Proof

Rebecca A. Snyder, Sharon E. Phillips, Kyla P. Terhune — 2012-05-07

Objective: The purpose of this study was to determine the impact of the initiation of a pediatric surgery fellowship on general surgery resident operative volume at 1 major academic institution. Design: Retrospective review of operative records obtained from the Accreditation Council for Graduate Medical Education (ACGME) general surgery resident and pediatric surgery fellow case logs. Data collected included number and type of pediatric index cases per year, number of total pediatric surgery cases per year, and number of total cases logged as primary surgeon to date. Setting: Vanderbilt University School of Medicine Department of Surgery, which has an accredited general surgery program, finishes 7 chief residents per year during the study period, and instituted a new pediatric surgery fellowship in 2007. Participants: Case logs submitted by third and fourth year general surgery residents and first and second year pediatric surgery fellows were studied. Results: The number of pediatric attending surgeons, relative value units (RVUs), and hospital admissions increased from 2003 to 2011. The median number of pediatric index cases performed by a resident decreased after the onset of fellowship from 34 cases to 23.5 cases per year (p < 0.001). The median number of total cases that residents performed on the pediatric surgery rotation also decreased from 74 to 53 cases per year after onset of the fellowship (p < 0.001). Conclusions: Even with an increase in the number of attending surgeons, RVUs, and admissions, the fellowship resulted in a decrease in general surgery resident index and overall case volume in pediatric surgery. Although operative volume is only 1 measure of surgical educational value, these findings suggest that the addition of surgical fellowships affects the educational experience of general surgery residents. We recommend that residency programs establish goals and calculate any potential impact on general surgery resident case volume before initiating a new surgical fellowship.

From Theater to the World Wide Web—a New Online Era for Surgical Education - Corrected Proof

D. Peter O'Leary, Mark A. Corrigan, Seamus M. McHugh, A.D. Hill, H. Paul Redmond — 2012-05-01

Introduction: Traditionally, surgical education has been confined to operating and lecture theaters. Access to the World Wide Web and services, such as YouTube and iTunes has expanded enormously. Each week throughout Ireland, nonconsultant hospital doctors work hard to create presentations for surgical teaching. Once presented, these valuable presentations are often never used again. Aims: We aimed to compile surgical presentations online and establish a new online surgical education tool. We also sought to measure the effect of this educational tool on surgical presentation quality. Methods: Surgical presentations from Cork University Hospital and Beaumont Hospital presented between January 2010 and April 2011 were uploaded to http://www.pilgrimshospital.com/presentations. A YouTube channel and iTunes application were created. Web site hits were monitored. Quality of presentations was assessed by 4 independent senior surgical judges using a validated PowerPoint assessment form. Judges were randomly given 6 presentations; 3 presentations were pre-web site setup and 3 were post-web site setup. Once uploading commenced, presenters were informed. Results: A total of 89 presentations have been uploaded to date. This includes 55 cases, 17 journal club, and 17 short bullet presentations. This has been associated with 46,037 web site page views. Establishment of the web site was associated with a significant improvement in the quality of presentations. Mean scores for pre- and post-web site group were 6.2 vs 7.7 out of 9 respectively, p = 0.037. Conclusions: This novel educational tool provides a unique method to enable surgical education become more accessible to trainees, while also improving the overall quality of surgical teaching PowerPoint presentations.

Residents Can Successfully Teach Basic Surgical Skills in the Simulation Center - Corrected Proof

Luise I.M. Pernar, Douglas S. Smink, Gloria Hicks, Sarah E. Peyre — 2012-04-18

Objectives: Basic surgical skills are frequently taught to surgical interns in simulation centers. Faculty recruitment for teaching of these sessions can be difficult. The goal of this study was to determine whether senior surgical residents can effectively teach basic surgical skills to provide an alternative to faculty-led instruction. Design, Setting, and Participants: Academic medical center. Twenty-eight surgical interns. In this randomized controlled trial, interns were randomized to receive teaching by either faculty or senior residents. Two-hour teaching sessions for each group consisted of modeling and guided practice. All interns underwent baseline knot-tying and suturing skill assessment using a previously validated standardized task scoring scheme and completed a confidence survey. After teaching sessions, both groups underwent repeated skill testing and were again surveyed. Results: Twenty-eight interns started in the surgery program at our institution during the year of this study. Seventeen of 27 (62.9%) interns participated in both teaching sessions and completed all skill assessments and surveys; 7 (41.2%) interns were taught by faculty, 10 (58.8%) by residents. Overall, skills training improved in both groups for knot-tying, running suture, and subcuticular suture performance. Confidence performing knot-tying tasks also improved. Interns taught by faculty members and residents demonstrated similar levels of improvement in speed and accuracy, although faculty instruction improved speed of performing the simple suturing task (−144 vs −27 s, p = 0.04). Conclusions: In the simulation center, teaching by senior surgical residents and faculty members resulted in comparable improvement in interns' basic surgical skills. These findings could increase the skill instructor pool for teaching in the simulation center, potentially easing recruitment and providing senior residents with teaching opportunities.

Measuring the Surgical Academic Output of an Institution: The “Institutional” H-Index - Corrected Proof

Kiran K. Turaga, T. Clark Gamblin — 2012-04-09

Introduction: The Hirsch index is a novel index that combines the number of publications and citations in measuring the research output of researchers. We hypothesized that the h-index can be used to measure the academic success of an institution in a subject area (surgery) and compared this measure to previously published measures of ranking institutions. Methods: We identified the top 10 research medical schools as designated by the United States News and World Report 2010. The h-index for an institution was obtained in 3-year periods for articles published in surgery. Independent rankings from the NIH and other web sites were then used to compare with our newly generated rankings. Results: The median h-index for institutions was 52.5 (46–54) for 2000–2002, 50 (44–52) for 2003–2005, 35.5 (33–40) for 2006–2008, and 15.5 (13–16) for 2009–2011. The percentage of self citations was the highest in publications from Harvard University (22.2%) and the lowest from Columbia University (10%) in the years 2009–11. Our ranking closely mirrored the United States News and World Report, and Harvard Medical School remains the top ranking in the field of surgery, although NIH funding-based ranking may suggest otherwise. Conclusions: The institutional h-index appears to be a viable indicator for the measure of academic success of institutions in a subject area. Despite limitations, it yields objective data regarding the citations and number of articles published by an institution in a subject area and could be used to measure performance.

Quality Improvement Requirement - Corrected Proof

John A. Weigelt — 2012-03-23

I admit to being a retired program director. I am also an individual who is very worried about the future of our training programs. My worry is global. It does not focus on work hours or case numbers, but on the ever expanding material our programs are expected to teach. Where do our august accreditation organizations believe we will find the resources and time to accomplish all these requirements? I wish to address the quality improvement requirement specifically.

Master Surgeons' Operative Teaching Philosophies: A Qualitative Analysis of Parallels to Learning Theory - Corrected Proof

2012-03-23

Objectives: Practicing within the Halstedian model of surgical education, academic surgeons serve dual roles as physicians to their patients and educators of their trainees. Despite this significant responsibility, few surgeons receive formal training in educational theory to inform their practice. The goal of this work was to gain an understanding of how master surgeons approach teaching uncommon and highly complex operations and to determine the educational constructs that frame their teaching philosophies and approaches. Design: Individuals included in the study were queried using electronically distributed open-ended, structured surveys. Responses to the surveys were analyzed and grouped using grounded theory and were examined for parallels to concepts of learning theory. Setting: Academic teaching hospital. Participants: Twenty-two individuals identified as master surgeons. Results: Twenty-one (95.5%) individuals responded to the survey. Two primary thematic clusters were identified: global approach to teaching (90.5% of respondents) and approach to intraoperative teaching (76.2%). Many of the emergent themes paralleled principles of transfer learning theory outlined in the psychology and education literature. Key elements included: conferring graduated responsibility (57.1%), encouraging development of a mental set (47.6%), fostering or expecting deliberate practice (42.9%), deconstructing complex tasks (38.1%), vertical transfer of information (33.3%), and identifying general principles to structure knowledge (9.5%). Conclusions: Master surgeons employ many of the principles of learning theory when teaching uncommon and highly complex operations. The findings may hold significant implications for faculty development in surgical education.

E-Learning Resources for Vascular Surgeons: A Needs Analysis Study - Corrected Proof

Seán J. Mâtheiken, Daniëlle Verstegen, Jonathan Beard, Cees van der Vleuten — 2012-03-14

Objectives: To obtain the views of vascular surgeons about online resources in their specialty as a guide to future e-learning development. Design: A focused questionnaire regarding e-learning resources in vascular surgery was circulated online. A combination of structured and open-ended questions addressed users' ranking of various resource types, examples of presently used websites, suggestions for future growth, and the opportunity to become actively involved in e-learning development. The responses were collected over a 4-week period and remained anonymous. Setting: The study was conducted online at http://www.vasculareducation.com as part of an ongoing project on e-learning for vascular surgeons by the Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands. Participants: The survey population consisted of vascular surgeons and surgical trainees in Europe. The participants were contacted via their membership of the European Society for Vascular Surgery and national academic or administrative vascular surgical organizations. Demographic information was collected about clinical seniority and country of work. Results: In all, 252 responses were obtained. Respondents favored the development of a variety of online resources in vascular surgery. The strongest demand was for illustrations and videos of surgical techniques, followed by an interactive calendar and peer-reviewed multiple-choice questions. Overall, 46% of respondents wished to contribute actively toward e-learning development, with consultants being more willing than trainees to do so. Conclusions: Members of the vascular surgical community value online resources in their specialty, especially for procedural techniques. Vascular surgeons would like to be actively involved in subsequent development of e-learning resources.

Objective Assessment of Surgical Training in Flexor Tendon Repair: The Utility of a Low-Cost Porcine Model as Demonstrated by a Single-Subject Research Design - Corrected Proof

Elisabeth Zetlitz, Scott Cameron Wearing, Alexander Nicol, Andrew Mackay Hart — 2012-03-02

Objectives: This study evaluated the utility of a porcine flexor tendon model and standard biomechanical testing procedures to quantify the acquisition of surgical skills associated with Zone II flexor tendon repair in a trainee by benchmarking task performance outcomes relative to evidence-based standards. Study design: Single-subject repeated measures research design. Bench-top set-up of apparatus undertaken in a University Research laboratory. After initial directed learning, a trainee repaired 70 fresh flexor digitorum profundus tendons within the flexor sheath using either a Pennington or ventral-locking-loop modification of a two-strand Kessler core repair. Tendon repairs were then preconditioned and distracted to failure. Key biomechanical parameters of the repair, including the ultimate tensile strength (UTS), yield strength, 3 mm gap force and stiffness, were calculated. Repairs were divided into 3 categories, early (first 10 days), intermediate (ensuing 10 days), and late repairs (final 10 days), and potential changes in repair properties over the training period were evaluated using a general linear modeling approach. Results: There was a significant change in the mechanical characteristics of the repairs over the training period, evidencing a clear learning effect (p < 0.05). Irrespective of the repair technique employed, early and intermediate repairs were characterized by a significantly lower UTS (29% and 20%, respectively), 3 mm gap (21% and 16%, respectively), and yield force (18% and 23%, respectively), but had a higher stiffness (33% and 38%, respectively) than late repairs (p < 0.05). The UTS of late repairs (47–48 N) were comparable to those published within the literature (45–51 N), suggesting surgical competence of the trainee. Conclusions: This simple, low-cost porcine model appears to be useful for providing preclinical training in flexor tendon repair techniques and has the potential to provide a quantitative index to evaluate the competency of surgical trainees. Further research is now required to identify optimal training parameters for flexor tendon repair and to develop procedure-specific standards for adequate benchmarking.

Cutting Errors in Surgery: Experience Limits Underestimation Bias in a Simulated Surgical Environment - Corrected Proof

Neha Malhotra, Jamie M. Poolton, Mark R. Wilson, Rich S.W. Masters — 2012-03-02

Objective: Error management is crucial in surgery and needs to be developed through appropriate training and education. Research suggests that perceptual errors may be more likely in laparoscopic environments. The objective of this work is to investigate error management by novices compared with experienced surgeons when performing a simple simulated incision in a visually challenging environment. Methods: Novices (n = 20) and experienced surgeons (n = 11) viewed pairs of horizontal lines on a laparoscopic monitor. Participants were asked to replicate the line lengths by making simulated incisions. The task was completed with or without online visual feedback of the incising hand. In a second phase of the study, the task was complicated by embedding the lines within a perceptual illusion (i.e., Ponzo illusion). Results: Incision lengths generally were shorter than the actual lengths of the viewed lines for all participants. For the novices, however, this underestimation bias was exacerbated when visual feedback of the incising hand was unavailable (p < 0.001), whereas the surgeons were not affected by loss of vision of the incising hand (p = 0.864). Furthermore, novices were influenced by the perceptual illusion designed to alter perceptions of line length (p = 0.021), whereas the surgeons did not appear to be influenced by the illusion (p = 0.945). Conclusions: A perceptual bias towards incision length underestimation may be present when surgery involves a laparoscopic monitor; however, surgical experience may protect against accentuation of the underestimation bias when the task becomes more visually challenging. The bias is discussed using the framework of error management theory.

Implications of Current Resident Work-Hour Guidelines on the Future Practice of Surgery in Canada - Corrected Proof

2012-02-06

Objective: Work-hour restrictions have had a profound impact on surgical training. However, little is known of how work-hour restrictions may affect the future practice patterns of current surgical residents. The purpose of this study is to compare the anticipated career practice patterns of surgical residents who are training within an environment of work-hour restrictions with the current practice of faculty surgeons. Design: An electronic survey was sent to all surgery residents and faculty at 2 Canadian university-affiliated medical centers. The survey consisted of questions regarding expected (residents) or current (faculty) practice patterns. Results: A total of 149 residents and 125 faculty members completed the survey (50.3% and 52.3% response rates, respectively). A greater proportion of males were in the faculty cohort than in the resident group (77.6% vs 62.4%, p = 0.0003). More faculty than residents believed that work-hour restrictions have a negative impact on both residency education (40.8% vs 20.8%, p = 0.008) and preparation for a surgical career (56.8% vs 19.5%, p < 0.0001). Compared with current faculty, residents plan to take less call (p < 0.0003), work fewer days of the week (p < 0.0001), are more likely to limit their duty hours on postcall days (p = 0.009), and take parental leave (p = 0.02) once in practice. Male and female residents differed somewhat in their responses in that more female residents plan to limit their postcall duty hours (55.4% vs 36.5%, p = 0.009) and to take a parental leave (51.8% vs 16.1%, p < 0.0001) compared with their male resident colleagues. Conclusions: Current surgical residents expect to adopt components of resident work-hour guidelines into their surgical practices after completing their residency. These practice patterns will have surgical workforce implications and might require larger surgical groups and reconsideration of resource allocation.

Basic Laparoscopic Training Using the Simbionix LAP Mentor: Setting the Standards in the Novice Group - Corrected Proof

2012-02-06

Background: Virtual reality devices are becoming the backbone for laparoscopic training in surgery. However, without knowledge of the achievable metrics of basic training within the trainee group, these simulators cannot be used effectively. Currently, no validated task metrics of the performance of larger trainee groups are available. Study design: From April 2004 to December 2009, we collated an extensive prospective database using the Simbionix LAP Mentor (Simbionix USA, Cleveland, Ohio) for basic laparoscopic training of novice surgeons. This database was used to determine benchmarks for basic skill exercises and procedural tasks that combine stimulus to improve and feasibility with acceptance of the training program and the goal to train for safe surgery. Results: In all, 18,996 task performances of 286 novice trainees were analyzed. For the basic skill exercises, the total time for correct execution ranged between 45 seconds for basic skill 3 (eye-hand coordination) and 269 seconds for basic skill 9 (object placement). For the procedural tasks, the total time for correct execution ranged between 68 seconds for procedural task 1 (clipping and cutting) and 256 seconds for procedural task 3 (dissection). The total time to task completion depended mainly on right instrument path length with high correlation to left instrument path length. Learning curve analyses of the 4 procedural tasks demonstrated performance plateaus after 10–15 repetitions. Most complications occurred during the initial repetitions of the respective task. The best quartile of performances was chosen as peer group benchmark because it provides sufficient stimulus for improvement without discouraging trainees, thus enhancing adherence to the training program. The benchmark for safety and accuracy parameters was set at a predefined level of 95% correct execution. Conclusions: As experience with virtual reality (VR) training is growing, curricula must be based on benchmarks for efficient training derived from large trainee groups to optimize use of the still costly simulators. Safety parameters should be included in trainee assessment. We share a set of metrics that take into account both performance and feasibility for basic laparoscopic training of surgical novices using the Simbionix LAP Mentor.

A New Training Model for Adult Circumcision - Corrected Proof

Mohamed Ismat Abdulmajed, Matthew Thomas, Iqbal S. Shergill — 2012-01-27

Background: Adult circumcision is an extremely common surgical operation. As such, we developed a simple model to teach junior doctors the various techniques of circumcision in a safe, reliable, and realistic manner. Materials and Methods: A commonly available simulated model penis (Pharmabotics, Limited, Winchester, United Kingdom) is used, which is then covered with a 30-mm diameter, 400-mm long, double-layered simulated bowel (Limbs & Things, Bristol, United Kingdom). The 2 layers of the prepuce are simulated by folding the simulated bowel on itself. The model has been officially adopted in the UroEmerge hands-on practical skills course—approved by the Royal College of Surgeons in the United Kingdom, and all participants were asked to provide feedback about their experience on a scale from 1 to 10 (1 = extremely unsatisfied and 10 = excellent). Results: The model has been used successfully to demonstrate, teach, and practice adult circumcision as well as other penile procedures with rating by trainees ranged from 7 to 10 (median: 9), and 9 of 12 trainees commented on the model using expressions such as “life like,” “excellent idea,” or “extremely beneficial.” Conclusions: The model is particularly useful as it is life like, realistic, easy to set up, and can be used to repeatedly demonstrate circumcision, as well as other surgical procedures, such as dorsal slit and paraphimosis reduction.