The journey from medical student to certified physician is landmark. But for those pursuing longevity in their practice and academic careers, it’s only the beginning. The periodic checkpoint known as Maintenance of Certification (MOC) is increasingly rigorous—and for good reason. The question remains: Is maintenance of certification harder than initial board certifications?

Initial Board Exam vs. MOC

Initial board certification typically evaluates a physician’s knowledge and clinical judgment at one point in time—often soon after residency or fellowship. It signals readiness to practice. By contrast, a Maintenance of Certification exam challenges whether you are still ready. As medicine evolves at a break-neck pace, and robotics and AI take over more functions, certifying boards are pushing MOC as a tool to ensure practicing physicians remain current.

Take for instance the American Board of Internal Medicine (ABIM). Its MOC program emphasizes time-specific certification, citing evidence linking recertification with better performance in practice. This stands in contrast to a one-and-done certification. While evidence is supportive, it’s worth noting it’s funded by ABIM—raising questions of bias.

Why is the MOC process inherently more demanding? For early-career doctors and fellows shaping tomorrow’s workforce, the answer lies in the structure: periodic assessments, educational activities, professional standard adherence and more. It’s not simply an exam, but a sustained process of lifelong learning.

Benefit and burden of MOCs

The headline benefit is clear: MOC is designed to maintain standards of quality care. For the physician, it signals commitment to ongoing growth. For patients and institutions, it offers reassurance the physician is staying current with evidence-based practice.

Yet the burden is also real. Many trainees and seasoned physicians view MOC as an extra hurdle: additional time commitment, cost, continuing education credits and standardized testing fatigue. Some critics argue the cost and logistics of MOC detract from clinical time or meaningful educational pursuits.

The conversation among trainees often centers on this tension: Is the rigor of MOC merit based or merely bureaucratic? Given how medicine changes—rapid adoption of telehealth, evolving guidelines (e.g., in diabetes or cardiovascular care) and new modalities like CAR-T therapy—MOC’s insistence on staying current seems increasingly justified.

History of MOC

The concept of MOC emerged from the notion a license or certification early in a physician’s career should not imply a lifetime stamp of expertise. In response, U.S. boards began rolling out MOC programs in the early 2000s. For example, ABIM implemented time-limited certificates and a multi-part MOC framework. Over time, MOC expanded to include modules, self-assessment, practice improvement projects and high-stakes exams.

The outcome? Over the past two decades, certification has shifted from a one-time event to a continuum. That shift means the challenge faced at board certification must now be renewed at regular intervals—and often with additional layers of process and evaluation.

Do you need MOCs for an academic career path?

For physicians considering academia, MOC becomes more than a credential—it’s foundational. Many academic institutions, tenure processes and hospital privileging mechanisms view active MOC status as evidence of continuous professional development. Maintaining board certification via MOC demonstrates to department chairs and promotion committees you’re not just grounded in the past but advancing knowledge and practice.

For those hoping to publish, teach, lead quality improvement initiatives or take on leadership roles, staying engaged in MOC is often nonnegotiable.

The goal of Maintenance of Certification (MOC)

At its core, the goal of MOC is twofold: to protect the patient and to support the physician. By ensuring practitioners revisit key knowledge domains and update their skills, boards aim to mitigate risks of outdated practice. Concurrently, MOC fosters professional growth, signaling a physician is committed to lifelong learning.

For trainees entering practice, that means MOC isn’t a box to check—it’s a mindset shift. You’re no longer just learning for a specialty exam; you’re planning for decades of evolving practice.

Requirements of ongoing maintenance

While specifics vary across boards, a typical MOC program incorporates four components:

1. Professionalism and ethics — adherence to professional standards
2. Lifelong learning and self-assessment — continuing medical education and module-based assessments
3. Assessment of knowledge, judgement & skills — periodic exams or quizzes covering core specialty content
4. Improvement in medical practice — projects that measure and improve actual care delivery

For example, the American Board of Pediatrics (ABP) requires pediatricians to complete modules, interactive longitudinal assessments and a high-stakes knowledge exam every few years. The American Board of Surgery (ABS) similarly demands continuous educational efforts and periodic proctored exams. These compare with initial certification, which tends to focus on one broad exam after training.

The value to patients and physicians

For patients, MOC provides a mechanism of assurance: your physician isn’t relying solely on residency-era learning but is up to date on the latest standards of care. For physicians—especially those early in their careers—embracing MOC means aligning with the evolving expectations of health systems, payers and academic promotion committees.

Importantly, many studies (some funded by certifying boards) show associations between time-specific certification (i.e., active MOC status) and improved physician performance. For example, physicians maintaining certification may demonstrate better adherence to guidelines or superior patient outcomes. However, as noted, some of that evidence originates from the boards themselves, which underscores the need for ongoing independent evaluation.

Cost to maintain certification

The economic burden of MOC is real: exam fees, module subscriptions, time away from clinical duties and potentially lost revenue. For physician trainees preparing for fellowship and beyond, this cost must be framed as an investment in long-term professional capital. Keeping current avoids the risk of falling behind in practice expectations, privileging or academic promotion.

Maintenance of certification examples

• ABIM MOC: Internal medicine physicians engage in ongoing knowledge assessments, modules and a high-stakes exam every multiple years.
• ABP maintenance: Pediatricians complete online modules and exams designed to retain and update core competencies.
• ABS continuous certification: Surgeons meet performance criteria, complete educational selections and take periodic secure exams.
  These processes all share the same logic: the exam and education regimen is more rigorous than the initial certification because it demands continuous renewal, rather than a one-time passage.

The message behind MOCs is clear: Your initial board certification is the foundation—but the structure of MOC is built to keep you resilient, current and competitive. Evolving demands of healthcare, combined with the expectations of academics, hospitals and patients, make MOC more than a formality—it’s a career-long commitment to excellence.

Whether you’re a trainee wrapping up residency or entering fellowship, or you’re a practicing physician, it’s valuable to adopt an MOC mindset: continuous assessment, lifelong learning and readiness for whatever changes medicine delivers next. As the stakes rise, embracing the rigor doesn’t just benefit you—it benefits patients, your team and the future of care.

To gain a broader understanding of physician board prep and other medical career topics, visit the resource center at PracticeLink.com.