The term “board-certified” once had a clear, consistent definition. A physician had achieved strict training and examination standards, enabling them to practice with assurance throughout the country. However, that clarity has diminished. Nowadays, certification and recertification criteria vary not only by specialty but also by the specific board to which one belongs. What used to be a singular national benchmark has fragmented into a collage of regulations, fees, and timelines that appear to prioritize administrative survival over actual learning.
One title, numerous rule sets
Let’s envision a few physicians functioning within this framework, sharing their experiences during every conference coffee break.
Dr. Nguyen, a hospitalist, possesses certifications from both the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM). To remain compliant, she must manage two distinct portals, two different question banks, two separate annual fees, and two varying approaches to “continuous learning.”
In an adjacent office, Dr. Alvarez, a surgeon, recertifies with the American Board of Surgery (ABS). His process is entirely dissimilar: forty online questions per year, several hundred dollars in fees, and 150 CME hours every five years.
Simultaneously, Dr. Carter, a pediatrician, logs into the American Board of Pediatrics (ABP) website quarterly for “MOCA-Peds” questions, each derived from topics that change annually.
All of them hold the same “board-certified” designation. Yet the effort involved in maintaining that designation, in terms of hours, financial cost, and complexity, varies significantly.
The path to this point
The American Board of Medical Specialties (ABMS) supervises 24 member boards, each granted the independence to create its own maintenance program. ABMS establishes broad principles for “continuing certification,” but leaves the details (number of questions, CME credit requirements, cycle duration, and expenses) to the individual boards.
This autonomy was intended to honor the diversity of medical fields. In reality, it has created a regulatory free-for-all. Some boards now offer longitudinal online assessments, others maintain ten-year exams, and several utilize hybrid systems that confuse even the most organized practitioners. These inconsistencies raise practical and ethical dilemmas: If maintenance of certification is essential for public safety, why should its stringency be contingent on which board a physician chose to join decades prior?
The practical scenario
Dr. Singh, a fictional yet relatable gastroenterologist, retains certifications in both internal medicine and gastroenterology. Her ABIM dashboard monitors MOC points and LKA participation; her subspecialty board mandates a separate attestation cycle and fees. She holds active licenses in four states for locum assignments, each requiring its own CME categories and renewal timelines.
By her estimation, she dedicates approximately 120 hours annually to educational obligations, less than half of which enhances her procedural or diagnostic skills. The remainder is spent on redundant or state-specific modules that have never demonstrated a positive impact on patient outcomes. Her situation is not uncommon. Multi-certified physicians frequently grapple with overlapping MOC responsibilities that differ not by logical reasoning but by historical happenstance.
A void of data
Proponents of the system contend that various specialties necessitate different maintenance frameworks. A cardiologist’s evolving technology differs from a psychiatrist’s therapeutic context. That’s accurate. However, if the diversity of practice warrants differing processes, we should at least possess data indicating which models are most effective.
We do not.
To date, there have not been comprehensive studies evaluating the effectiveness of the assorted maintenance systems across ABMS boards. We lack knowledge on whether longitudinal testing enhances retention, if CME-intensive models lead to greater adherence to guidelines, or if shorter renewal intervals contribute to safer care. Each board functions as its own experiment, with physicians as unconsenting participants.
The emergence of alternative boards
Frustration with traditional boards has catalyzed the rise of the National Board of Physicians and Surgeons (NBPAS), which provides recertification based solely on CME completion and professional standing. NBPAS eliminates exams and points altogether.
Hospitals and payers are gradually adapting. By 2025, hundreds of institutions will accept NBPAS credentials, although coverage remains inconsistent. A physician might be acknowledged in one hospital but denied in another, a ridiculous circumstance for a profession supposedly unified under national standards. This fragmented credentialing landscape has complicated professional mobility. A doctor moving across state lines for locums work may find that identical training and CME hours qualify in one facility, but not in another.
Locums caught in the turmoil
Nowhere is the disorder more evident than in locums and telemedicine practices. Physicians licensed in multiple states must navigate not only different CME topics but also contrasting board expectations that do not align with licensure.
Consider Dr. Harris once more, the gastroenterologist mentioned previously. She handles short-term assignments in six states. To maintain compliance, she tracks six sets of CME requirements and two board-certification timelines. A course on sedation safety taken for her ABIM credit may not meet Florida’s patient-safety stipulation.