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This section refers to difficulties that can be encountered in a variety of aspects of endoscopic procedures. Strategies to navigate across sphincters, around sharp curves, and through areas of resistance typically require achievement of a basic level of competence in navigation prior to attempting to master these challenges. Novice endoscopists typically struggle with traversing the pylorus if they have not mastered when to use small amounts of tip deflection rather than large movements via torque application in order to generate rotation of the scope upon its long axis for example. Another area of uncertainty for trainees is how much resistance is normal, such as when encountering paradoxical scope movement. This becomes particularly important when traversing strictures or altered anatomy (e.g., advanced diverticular disease in colonoscopy, Billroth II anastomosis in ERCP, etc.). Again, this requires both attention to a cognitive component and a technical component of training. Although it may technically be possible to traverse a malignant stricture, clearly consideration must first be given in training to the potential advantages and disadvantages of other modalities or approaches before this is attempted. A similar analogy applies to the difficult cannulation during ERCP. A trainee can too easily become consumed with technical efforts to overcome the obstacle and must not lose sight of the relative indications for persistence as the procedure proceeds. What may seem obvious and commonplace to an experienced endoscopist may not be known or understood by trainees. This also highlights the importance of checking understanding with trainees during endoscopic training, particularly if the trainee is new to the trainer.

Recognition and prevention of difficulties are a major component of ensuring patient safety and comfort. This may require using a lower setting of air insufflation for instance or defining the amount of the procedure that should be performed by trainees (e.g., limiting polypectomy, sphincterotomy, or other therapeutic steps until the preliminary diagnostic skills have been mastered). This emphasizes the importance of establishing clear limits on what the trainee is expected to do during a procedure and when the trainer will take over the procedure. By doing this, the teacher will manage the emotional aspects of learning better and avoid the negative connotation of taking over a procedure. The other important components of training (covered in the Chapter 3) include the medicolegal aspects, appropriate informed consent, and so on.