For years, the conversation about board certification has centered on fairness, cost, and evidence. But there is another consequence that gets far less attention: how these systems affect the supply of practicing physicians.
America’s physician shortage isn’t theoretical anymore. It is here. Hospitals are scrambling to fill call schedules, rural communities are waiting months for specialist appointments, and medical groups are watching senior clinicians retire earlier than planned. Among the many pressures driving this trend, burnout, administrative overload, and declining autonomy, the demand for endless certification exams and maintenance cycles has quietly become one of the most avoidable.
A shortage decades in the making
The Association of American Medical Colleges projects a shortage of up to 86,000 physicians by 2036. The gap is growing fastest in primary care, general surgery, and internal medicine subspecialties, the very fields that require ABIM certification and recertification.
At the same time, the median age of practicing physicians keeps rising. Nearly half are over 55. That means the next decade will bring not just gradual attrition, but a wave of retirements.
Under normal conditions, that would be worrying enough. Under current certification demands, it is becoming a crisis.
“I just don’t want to take another test.”
Let’s imagine a few familiar physicians approaching that inflection point.
Dr. Reynolds, who certified before 1990, is still practicing three days a week at 68. He was grandfathered under ABIM’s lifetime rule and no longer has to maintain certification. He loves patient care and sees no reason to stop.
Dr. Patel, 52, certified in 2003. Her next MOC cycle comes with a renewal exam or ongoing LKA participation, along with fees and point tracking. She has spent decades balancing clinical practice, administration, and family life. The idea of “reproving” her competence through another test feels insulting. She quietly plans to retire at 57, five years earlier than she intended.
Multiply that decision across thousands of mid-career physicians, and you begin to see how a policy designed to uphold standards may be shrinking the workforce that patients depend on.
The bureaucratic tipping point
The last decade has pushed physicians to a bureaucratic breaking point. EMRs, prior authorizations, quality dashboards, and compliance attestations already eat up hours that could be spent with patients.
Layer on state-specific CME requirements, annual hospital credentialing, and the ABIM’s version of “continuous assessment,” and the result is an impossible equation. Many doctors describe MOC not as continuing education but as the final straw, one more hoop to jump through in a career already drowning in them.
Surveys consistently show that 40 to 50 percent of physicians report symptoms of burnout, and regulatory demands are among the top three causes. In a 2024 Medscape survey, one in five mid-career physicians cited MOC or other certification mandates as a contributing factor to early retirement.
Hospitals feel it first
Hospital administrators rarely think about certification policy until it lands on their desk as a staffing emergency.
Dr. Harris, the fictional gastroenterologist who covers locums assignments across several states, recently turned down a six-month contract because her ABIM MOC cycle had lapsed during a transition between jobs. The credentialing process would have taken longer than the assignment itself.
Her experience isn’t unique. Credentialing departments now find themselves delaying start dates, or losing candidates entirely, because MOC paperwork, CME verification, or recertification exams aren’t complete.
In rural and community hospitals, where one gastroenterologist or cardiologist might cover an entire region, a single lost physician can mean cancelled procedures and months-long delays for patients.
The locums bottleneck
Locums tenens work once offered a flexible bridge for late-career physicians easing toward retirement. But the complexity of maintaining multiple state licenses and certifications has made that bridge narrower every year.
A surgeon licensed in five states must now navigate five different CME topic lists, several unique license portals, and whichever maintenance model his specialty board uses. For many, it simply isn’t worth it.
This loss of mobility hurts more than convenience; it hurts capacity. Locums physicians are often the ones filling weekend call, holiday coverage, and small-hospital gaps. When administrative friction drives them away, the remaining staff are forced into unsustainable workloads, further accelerating burnout and attrition.
The ripple effect on communities
When one physician leaves, the impact extends beyond the hospital walls.
In smaller towns, retiring specialists often aren’t replaced at all. Younger physicians, already burdened with debt and facing constant certification demands, are reluctant to relocate somewhere they will be the only cardiologist or gastroenterologist in a 200-mile radius.
For those communities, the loss of a single provider can mean longer travel times, delayed diagnoses, and poorer outcomes. Patients may wait months for colonoscopies or heart evaluations that used to happen within weeks.
Certification policy isn’t solely responsible for these shortages, but it plays a measurable role by nudging experienced doctors toward the exit earlier than they otherwise would have gone.
An aging workforce meets a rigid system
One of the most striking ironies is how little the maintenance system accommodates physician career stage.
A doctor with 30 years of clean practice, decades of CME participation, and excellent patient outcomes faces the same recertification demands as a newly minted attending. There is no pathway that recognizes cumulative experience, mentorship, or peer reputation.
That rigidity sends a message: You are only as competent as your last exam score.
For older physicians, especially those in smaller or private practices, that message is often the last straw. The choice becomes simple: Retire early or spend time and money proving what a lifetime of practice has already shown.
The economics of exit
Replacing a single experienced physician can cost a hospital between $250,000 and $1 million when factoring in recruitment, credentialing delays, and lost revenue.
Now multiply that across hundreds of early retirements spurred by certification fatigue, and the financial impact becomes staggering. Hospitals then turn to locums agencies or temporary staffing, which cost substantially more per hour and provide less continuity of care.
The irony is painful: Boards collect fees in the name of public accountability, while the resulting workforce attrition leaves patients with less access to consistent care.
Evidence, again, nowhere to be found
Supporters of MOC sometimes argue that “you can’t quantify what doesn’t happen,” implying that the program prevents errors we will never see. But that is not how medicine works. Every policy that consumes time and money should be measured against outcomes.
To date, there is no evidence linking MOC participation or recertification exams to workforce retention, patient safety, or quality improvements. In contrast, there is growing evidence that excessive administrative burden contributes directly to burnout and early retirement.
We are, in effect, draining the physician workforce with no measurable return.
A smarter approach
Reform doesn’t have to mean abandoning professional standards. It means aligning them with reality. A more rational model could include:
- Tiered maintenance by career stage: Early-career physicians might undergo more frequent assessment; mid-career physicians could focus on peer-reviewed quality metrics; late-career physicians could emphasize mentorship and outcomes tracking rather than exams.
- Automatic CME integration: CME already measures engagement with current evidence. Every accredited CME hour should automatically count toward maintenance, eliminating duplicative systems.
- Simplified portability for locums: A national credentialing platform could recognize valid board certification across states, reducing redundant paperwork for physicians who travel or practice telemedicine.
- Outcome-based accountability: Link maintenance to real data, such as procedure outcomes, adherence to guidelines, and patient safety scores, instead of online tests.
- Incentives for retention: Hospitals, boards, and payers could create reduced-fee or streamlined maintenance pathways for physicians who agree to continue practicing in shortage areas.
The stakes are growing
The physician shortage is projected to worsen for at least the next decade. If current trends continue, we will have more administrators than physicians by 2030, a grim but realistic projection.
Meanwhile, boards continue to add incremental reforms and call it progress. The 2024 ABIM change, eliminating the two-year point requirement, was a welcome tweak, but it did nothing to reduce the underlying burden. The profession needs more than tweaks; it needs structural realignment.
Without it, certification will keep functioning as an unintended off-ramp for skilled physicians who might otherwise keep practicing for years.
What we lose when experience walks away
When a physician retires early, we don’t just lose a headcount; we lose mentorship, pattern recognition, and judgment, the tacit knowledge that can’t be taught in a textbook.
These are the clinicians who guide residents through complex cases, who have lived through the cycles of new drugs, new devices, and changing guidelines. Losing them means losing the human memory of medicine itself.
No exam can replace that.
The way forward
If certification bodies and policymakers truly want to protect patients, they should start by protecting the workforce that serves them.
That means acknowledging that more testing doesn’t equal better care, and that the most urgent crisis in medicine right now is not competence, but capacity.
The profession needs a maintenance model that keeps doctors learning and practicing, not testing and quitting. Because at this rate, the greatest threat to patient safety won’t be a physician who skipped a quiz; it will be the empty exam room where no physician remains at all.
Brian Hudes is a gastroenterologist.
