The current system of continuing medical education, maintenance of certification, and renewal of medical licenses can be quite burdensome and inefficient for all practicing physicians: medical doctors (M.D.s) and doctors of osteopathic medicine (D.O.s). D.O.s have opportunities for residency training and specialty certification which are not available to M.D.s. Not only are D.O.s required to satisfy unique educational requirements for state licensure which vary across jurisdictions, but they must also satisfy specialty board certification requirements which may or may not be recognized by the jurisdiction in which they practice. The purpose of this article is to identify the challenges for D.O.s, specializing in pediatrics in this case, in efficiently fulfilling requirements of state medical and osteopathic boards for licensure, as well as for specialty board certification. While initiatives in demonstration of continued fitness for practice are sometimes looked upon with concern by physicians, there is the potential that alignment of maintenance of certification, osteopathic continuous certification, and maintenance of licensure could actually reduce the inefficiencies and redundancies of the current regulation system. Barriers to practice should be avoided, while at the same time honoring the profession's responsibility to ensure that those who are caring for patients remain competent to do so.