The phrase “board-certified” once carried a universal meaning. A physician had met rigorous training and testing standards and could practice confidently anywhere in the country. That clarity has faded. Today, certification and recertification requirements differ not only by specialty but also by which board you happen to fall under. What was once a single national standard has splintered into a patchwork of rules, fees, and timelines that seem designed less for learning and more for administrative survival.

One title, many rulebooks

Let’s picture a few physicians working under this system, the kinds of experiences colleagues share at every conference coffee line.

Dr. Nguyen, a hospitalist, holds certifications from both the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM). To stay compliant, she must juggle two different portals, two different question banks, two different annual fees, and two different philosophies of “continuous learning.”

Across the hall, Dr. Alvarez, a surgeon, recertifies through the American Board of Surgery (ABS). His pathway is entirely different: forty online questions a year, a few hundred dollars in fees, and 150 CME hours every five years.

Meanwhile, Dr. Carter, a pediatrician, logs into the American Board of Pediatrics (ABP) site quarterly for “MOCA-Peds” questions, each drawn from topics that rotate annually.

All of them carry the same “board-certified” title. Yet the work required to keep that title, in hours, cost, and complexity, varies dramatically.

How we got here

The American Board of Medical Specialties (ABMS) oversees 24 member boards, each with autonomy to design its own maintenance program. ABMS sets broad principles for “continuing certification,” but the specifics (number of questions, CME credit requirements, cycle length, and cost) are left to the individual boards.

This independence was meant to respect the diversity of medical disciplines. In practice, it has produced a regulatory free-for-all. Some boards now offer longitudinal online assessments, others still require ten-year exams, and several have hybrid systems that confuse even the most organized physician. The disparities raise practical and ethical questions: If maintenance of certification ensures public safety, why should its rigor depend on which board a physician happened to join decades ago?

The working reality

Dr. Singh, a fictional but familiar gastroenterologist, keeps certifications in both internal medicine and gastroenterology. Her ABIM dashboard tracks MOC points and LKA participation; her subspecialty board requires a separate attestation cycle and fees. She maintains active licenses in four states for locum assignments, each with its own CME categories and renewal schedule.

By her own tally, she spends roughly 120 hours a year fulfilling educational mandates, less than half of which directly improve her procedural or diagnostic skill. The rest go toward duplicative or state-specific modules that have never been shown to enhance patient outcomes. Her situation isn’t unusual. Multi-certified physicians often shoulder overlapping MOC obligations that differ not by logic but by historical accident.

A data desert

Supporters of the system argue that different specialties require different maintenance models. A cardiologist’s evolving technology is not the same as a psychiatrist’s therapeutic landscape. That’s true. But if diversity of practice justifies diversity of process, we should at least have data showing which models work best.

We don’t.

To date, no comprehensive studies compare the effectiveness of the various maintenance systems across ABMS boards. We don’t know whether longitudinal testing improves retention, whether CME-heavy models produce better adherence to guidelines, or whether shorter renewal cycles translate into safer care. Each board operates as its own experiment, with physicians as the unconsenting subjects.

The rise of alternative boards

Dissatisfaction with traditional boards has fueled the growth of the National Board of Physicians and Surgeons (NBPAS), which offers recertification based solely on CME completion and professional standing. NBPAS eliminates exams and points entirely.

Hospitals and payers are slowly responding. As of 2025, hundreds of institutions accept NBPAS credentials, though coverage remains inconsistent. A physician may be recognized in one hospital but rejected in another, an absurd situation for a profession supposedly unified under national standards. This fractured credentialing landscape has made professional mobility harder, not easier. A doctor crossing state lines for locums work may discover that identical training and CME hours qualify in one facility but not the next.

Locums in the crossfire

Nowhere is the chaos clearer than in locums and telemedicine practice. Physicians licensed in multiple states must navigate not only different CME topics but also varying board expectations that fail to align with licensure.

Imagine Dr. Harris again, the gastroenterologist from our earlier article. She covers short-term assignments in six states. To maintain compliance, she tracks six sets of CME mandates and two board-certification schedules. A course on sedation safety taken for her ABIM credit may not satisfy Florida’s patient-safety requirement or Illinois’s opioid-prescribing CME.

She spends more time reconciling paperwork than reviewing the latest clinical trials. None of this redundancy has ever been shown to improve colonoscopy outcomes, reduce complications, or enhance patient satisfaction. If the goal of these systems is competence, they are stunningly inefficient ways to prove it.

Unequal effort, equal label

The most striking problem isn’t just the bureaucracy; it’s the unevenness of effort behind the same credential. A pediatrician’s quarterly quiz cycle may feel manageable, while a surgeon’s CME burden is massive. An internist under ABIM faces an annual fee and a continuous testing requirement, while a physician under a smaller board may have a simpler attestation every five years.

Patients, employers, and even insurers don’t see those differences. To them, “board-certified” is a single, trusted signal. But the reality behind that label has become anything but uniform.

The grandfather divide

Layered on top of all this is the generational divide between physicians who were “grandfathered” into lifetime certification and those who were not. Older physicians, certified before time-limited boards existed, can practice indefinitely without ever retesting. Younger physicians, often with greater clinical volume and exposure to newer therapies, face endless maintenance loops.

This inequity erodes morale and damages credibility. If ongoing testing is essential for patient safety, why are tens of thousands of physicians exempt? And if it’s not essential, why are younger colleagues paying for it?

What real reform would look like

To rebuild trust and bring coherence to certification, the profession should move toward a unified national framework built on transparency and reciprocity.

• Align maintenance across boards. Every board should meet a baseline standard: same renewal interval, CME equivalence, and outcome-based review. Specialty content can differ, but the scaffolding should be consistent.
• Reciprocity with state CME. Specialty-specific CME should automatically satisfy state license renewals and board-maintenance credits. A single learning activity ought to count everywhere.
• Evidence before enforcement. Before mandating new cycles or tests, boards should produce peer-reviewed evidence showing that those activities improve care or safety. Otherwise, the rule should sunset automatically.
• Equity in certification. Grandfathered physicians should either join a simplified maintenance track or carry a distinct lifetime designation so the public understands the difference.
• One digital credential. A national credentialing portal could unify CME, board status, and license verification. It would reduce redundancy, save costs, and let physicians focus on learning instead of paperwork.

The future of board certified

Medicine’s strength has always been its commitment to self-regulation, to holding itself accountable without outside intervention. But self-regulation requires credibility, and credibility demands coherence.

If certification remains a patchwork of inconsistent standards, opaque fees, and unproven testing models, others (legislators, insurers, or corporate health systems) will eventually step in to impose order. That outcome would serve no one.

The phrase “board-certified” should mean that a physician is current, competent, and continually engaged in meaningful education. It shouldn’t depend on which board they happened to join, where they practice, or how many passwords they remember. Until the system regains that clarity, the letters after our names will mean far less than the work we do in the exam room every day.

Brian Hudes is a gastroenterologist.