The tension between physicians and the American Board of Internal Medicine (ABIM) has simmered for a decade. What began as a professional debate over maintenance of certification (MOC) has evolved into a broader question of fairness, autonomy, and accountability. Now, the courts are involved, and the legal battles are revealing as much about the profession’s frustration as they are about the structure of American medicine.

A landscape of lawsuits

Since 2018, multiple physician-led lawsuits have challenged the legality of the ABIM’s business model. The most visible, Association of American Physicians & Surgeons (AAPS) v. ABIM, claims that the organization uses its monopoly on certification to force physicians into costly, time-consuming recertification cycles under threat of professional exclusion.

A federal district court initially dismissed much of the case in 2022, but in 2024, the Fifth Circuit Court of Appeals revived key portions, allowing it to proceed. The legal argument is complex, but the essence is simple: Physicians allege that ABIM’s MOC requirements, bundled with its initial certification monopoly, create an anticompetitive system that unfairly ties one product (initial certification) to another (ongoing maintenance).

It’s a case that gets to the heart of physician autonomy, and one that could reshape the entire certification landscape if courts ultimately find that MOC participation is being coerced under antitrust law.

More than just a legal fight

Let’s imagine a few different practicing physicians navigating the ripple effects of this controversy.

Dr. Nguyen, a hospitalist, needs her certification to stay on staff at her hospital. The credential is required by both the bylaws and her malpractice insurer. When she expresses skepticism about the value of MOC, her administrator reminds her that “certification is mandatory for hospital credentialing.” She has no real choice.

Across town, Dr. Lawson, a cardiologist in private practice, opts to drop out of MOC altogether after failing to see any clinical benefit. He still holds his original certification, but without ongoing maintenance, ABIM marks him as “not participating.” His insurer flags the change, his hospital reevaluates his privileges, and his profile on the ABIM website now implies his certification has “lapsed.”

Neither of these physicians is breaking the law, yet both are effectively trapped. Their livelihood depends on maintaining a credential that is, by most definitions, voluntary.

What the lawsuits argue

The plaintiffs in these cases argue that ABIM’s control over certification has become so entrenched that participation in its MOC program is no longer optional in any meaningful sense. They point out that hospitals, payers, and insurers often treat ABIM certification as a de facto requirement for employment or credentialing.

That’s where the legal argument of tying comes in, a concept from antitrust law that prohibits companies from forcing customers to buy one product as a condition of buying another. In this analogy, the “product” is certification: doctors must first purchase initial certification and then continually purchase MOC to maintain access to it.

ABIM counters that participation in MOC is voluntary, that its processes serve the public interest by ensuring ongoing competence, and that hospitals and insurers, not ABIM, make credentialing decisions.

Yet from the perspective of working physicians, the difference between voluntary and required has become semantic. In modern practice, “voluntary” certification is about as optional as paying your malpractice premium.

Credentialing as a choke point

At the heart of this conflict lies the modern credentialing ecosystem, a web of overlapping requirements that give MOC its real-world power.

Hospitals, insurers, and health systems increasingly use board certification status as a proxy for quality. The logic is straightforward: A certified physician has demonstrated competence through training and examination, so maintaining certification must signify continued excellence.

But this assumption has never been validated. No large-scale studies have shown that hospitals requiring MOC achieve better patient outcomes than those that do not. Instead, what has emerged is a circular system: Boards require maintenance, hospitals require board recognition, insurers require credentialing, and physicians must comply or risk professional exile.

The result is a quiet but powerful form of coercion, one that no single organization takes responsibility for.

The cost of compliance

Dr. Adams, a fictional but realistic mid-career pulmonologist, once calculated his own “MOC tax.” Between exam fees, travel, continuing medical education (CME) purchases, and time away from his practice, he spent roughly $5,000 every five years just to remain in good standing.

Multiply that across the more than 200,000 ABIM diplomates, and the financial magnitude becomes clear. The board’s tax filings reflect tens of millions in annual revenue tied directly to maintenance of certification.

Critics argue that this structure incentivizes the continuation of burdensome requirements regardless of their proven benefit. In their view, MOC has become less about professional development and more about sustaining an administrative enterprise.

Fragmented oversight, fragmented accountability

ABIM operates as one of 24 member boards under the American Board of Medical Specialties (ABMS). Each member board sets its own standards, timelines, and fees. While ABMS provides overarching principles, there is no unified accountability mechanism to evaluate whether these maintenance systems actually improve care.

Meanwhile, alternative certifying bodies such as the National Board of Physicians and Surgeons (NBPAS) have emerged, offering CME-based recertification without exams or point systems. Some hospitals and insurers accept NBPAS credentials; others don’t.

That inconsistency has created what might best be called “credentialing by ZIP code.” A physician might be recognized in one state but disqualified in another, not because of competence, but because of institutional politics.

Legal reform versus professional reform

Even if the lawsuits against ABIM eventually succeed, legal remedies alone may not fix the underlying problem. Courts can address anticompetitive behavior, but they cannot legislate professional coherence or rebuild trust between physicians and their certifying bodies.

True reform will require medicine itself to decide what continued certification should mean, and how to align it with actual, measurable outcomes.

That means defining what we are trying to prove through these processes. Is it ongoing competence? Lifelong learning? Patient safety? If the answer is “all of the above,” then the system must demonstrate evidence for each, not simply assume it.

An uneasy status quo

For now, the legal battles continue. ABIM’s reforms, such as the 2024 elimination of the two-year point check-in, were designed to reduce friction, not to address the monopoly question. The board continues to defend MOC as necessary for public accountability and professional integrity.

But among working physicians, skepticism runs deep. Many see the board’s moves as reactive, incremental changes made only under pressure from lawsuits and growing competition.

Dr. Patel (from our previous article) summed it up best during a recent grand rounds discussion:

“It’s not that we don’t believe in lifelong learning. We just don’t believe in paying for it twice.”

A path forward

Rebuilding trust will require more than eliminating redundant rules. It will demand transparency about where the money goes, evidence that the time and expense improve outcomes, and a reimagining of certification as a tool for learning, not punishment.

A good start would be a truly portable credentialing system that integrates CME, specialty maintenance, and state licensure. Physicians should be able to demonstrate ongoing competence through meaningful metrics: peer-reviewed case evaluations, clinical performance benchmarks, or documented quality improvement projects, all verified through a shared national database, not a dozen separate portals.

As for the courts, they may soon decide whether ABIM’s current structure crosses the legal line between quality assurance and market control. But even if the rulings go in ABIM’s favor, the profession’s confidence will not return until the system itself does more than check boxes and collect fees.

Until then, physicians will keep doing what they’ve always done: learning, improving, and caring for patients, often in spite of the very organizations that claim to represent that effort.

Brian Hudes is a gastroenterologist.