Therapeutic endoscopic ultrasound is a rapidly expanding field, requiring training beyond the 3-year gastroenterology fellowship and at least an additional year in a structured advanced endoscopy fellowship program with mentorship from an expert at a sufficiently high-volume center. Simulation models can provide initial instruction on technique and increase familiarity with the rapidly changing devices. Trainees must also be given a graduated level of independence to perform each step and, eventually, be able to practice on a variety of endoscopic targets. With structured competency markers, trainees can learn methods to maximize success and minimize the risk of complications.