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Identifying methods best suited to teach colonoscopy can be quite difficult. Traditionally, these skills have been taught at the bedside during patient‐based endoscopy. However, with computer simulation models, as well as live and ex vivo animal models, evidence would suggest that these alternatives to patient‐based endoscopy can impart some of these motor and cognitive skills [21, 22]. In the case of early motor skills, this can also be done more safely, economically, and with better patient outcomes [23].

A second problem with the current state of colonoscopy education is that skills are primarily taught all together from the first day without differentiation between beginning or intermediate skills. In traditional training, a trainee is commonly forced to attempt to learn intermediate skills such as loop reduction and navigation of fixed angulated turns at the same time he/she is learning simply how to use the dials and steer the scope. This produces a great deal of stress for the trainee not to mention some element of discomfort or even increased risk for the patient. Breaking the procedure down into individual skills, greater utilization of alternate teaching tools such as texts, multimedia, and simulation, training can proceed in a more stepwise fashion, starting with focused instruction of the most basic skills first and then on to more advanced skills when ready. Education literature has well established that building skills in a stepwise fashion is the most effective learning model [24]. This is not to suggest that these teaching aids will replace patient‐based training, but rather these training tools can be used to effectively augment patient‐based training and improve on the traditional training model. In this final section, we will examine the methods by which each of these skill groups previously outlined can best be taught.

The final focus of this chapter will be on methods to assess the mastery of these required skills by trainees. Accrediting bodies have placed a growing emphasis on assessment and documentation of competency, yet few programs do any type of formal evaluation other than a global subjective assessment of skills toward the end of training. This type of informal global assessment is fraught with biases inherent to subjective assessments. It also fails to identify struggling trainees early enough to provide timely remediation. Instead, assessment must be an ongoing process from the first scope performed during fellowship to the last. In general, there are four different types of assessment: written tests, performance tests, clinical observation methods, and a group of miscellaneous tests made up of oral examinations, portfolios, and the like [25]. Each can be used in a formative (testing primarily for the purposes of feedback or learning) or summative (testing for grading purposes) manner, yet as we will discuss, a specific testing method may be better suited for assessment of a particular skill. This chapter will address the best methods to provide continuous assessment of trainees' cognitive and motor skills (Table 6.2).

Table 6.2 How skills can be taught and assessed?

	Teaching methods	Assessment methods
Early skills (first 50 procedures)
Cognitive	Self‐directed learningTextsArticlesMultimedia aidsLectures	Written examsBoard‐type questionsFormative assessment during didacticsSimulationSedation/airway/complication management
Motor	Patient‐based trainingSimulation trainingComputer simulatorEx vivo course	Early formative assessmentObjective structured clinical examinations (OSCE)
Intermediate skills (50–250 procedures)
Cognitive A. Pathology recognition	Self‐directed learningTextPhoto AtlasMultimedia	Written examsPathology recognition
B. Decision‐making	Patient‐based trainingSocratic methodSelf‐directed learningMultimedia (GESAP)	Patient‐based trainingSocratic methodWritten examsBoard‐type questionsOngoing assessmentStandardized assessment tool
Motor	Patient‐based trainingSimulationEx vivo modelsScope locating deviceScopeGuide	Ontinuous assessment toolOSCEBovine model