PURPOSE OF REVIEW: Since the introduction of ERCP and EUS in the 1980s, the field of advanced endoscopy has witnessed significant growth, necessitating formalized fellowship training to ensure competency and patient safety. This article reviews the history and development of Advanced Endoscopy Fellowship (AEF) training in North America, outlining current challenges such as variability in training standards, case volume, and faculty expertise. RECENT FINDINGS: General gastroenterology fellowships with apprenticeship model training in advanced endoscopic procedures have been insufficient, prompting the establishment of Advanced Endoscopy Fellowship (AEF) programs across North America. There are emerging trends in interventional endoscopy training, such as competency-based education (CBE), simulation-based training (SBT), and video-based training (VBT). There are new pathways for specialized modular and robotic training and non-traditional routes for EUS and ERCP skill acquisition. Variability across AEF programs remains concerning. This highlights the need for expanded regulatory efforts by organizations like ASGE. Advanced endoscopy training continues to evolve with innovative educational models. However, addressing variability, resource constraints, and employment challenges will be essential to meet the expanding procedural demands of this field and improve patient outcomes.