When the assessment on your ABIM Internal Medicine certificate comes due, you have a decision to make: sit for the traditional 10-year Maintenance of Certification (MOC) exam, or answer questions every quarter through the Longitudinal Knowledge Assessment (LKA). Both draw on the same blueprint. They just fit into a working internist's life very differently.
Here's how the two compare, based on ABIM's January 2026 Internal Medicine blueprint and its published LKA materials, plus who each option tends to suit and how to prepare.
Same Blueprint, Different Formats
ABIM uses one Internal Medicine blueprint for both, and it's built around practice rather than training:
- Common conditions first. The assessments emphasize diagnosis and management of prevalent conditions, "particularly in areas where practice has changed in recent years," and put less emphasis on rare conditions.
- Recognition for specialist-managed conditions. For conditions usually managed by other specialists, the focus is recognition rather than management.
- Mostly outpatient. Most questions describe encounters in outpatient settings, with some in the hospital.
- High-importance topics dominate. At least 75% of questions address topics rated high importance, none address low-importance topics, and no more than 18% address low-frequency topics.
- Slightly different weights from initial certification. Cardiovascular disease is 15%; endocrinology, gastroenterology, infectious disease, and rheumatology and orthopedics are 10% each; pulmonary disease is 8%; hematology 4%; and psychiatry 3%. Compare the full list in our guide to the Certification blueprint.
If you practice as a hospitalist, ABIM also offers an Internal Medicine: Inpatient version of both options, with its own blueprint.
The 10-Year Exam and the LKA at a Glance
| 10-Year MOC Exam | LKA | |
|---|---|---|
| Questions | Up to 220 single-best-answer questions, about 50 of them unscored | 30 per quarter, 120 a year, 600 over a five-year cycle |
| When and where | A scheduled exam (see abim.org for dates and testing options) | Any time during the quarter, on a phone, tablet or computer |
| Resources | UpToDate for the entire exam | Any resource you'd use in practice, except another person |
| Time per question | Set by the exam's session timing | Five minutes, plus a bank of 30 extra minutes each year |
| Feedback | Results after the exam | Right after each question, with a rationale and references |
| Pass/fail decision | One exam, taken and passed every 10 years | One decision at the end of the five-year cycle |
| Staying on track | Register for and sit the exam | Open at least 500 of the 600 questions and meet the yearly participation requirement |
What "Open Book" Means for Each
The 10-year exam: You can use UpToDate for the entire exam, but open book doesn't mean unlimited time. Use it to confirm a detail, not to learn a topic from scratch, and decide during practice which kinds of questions are worth a lookup.
The LKA: ABIM says you can "access any resources used in practice," except another person. Its code of conduct allows printed or electronic resources used as you would in day-to-day practice, with firm limits:
- No help from anyone. You can't seek or receive help from other people in answering questions, or help another participant.
- No copying or sharing. You can't photograph, screenshot, copy or otherwise reproduce or transmit questions, answer choices, critiques or references.
- No discussing questions. You can't discuss LKA content with anyone, and the rationales and references you receive are for your use only.
Read the code of conduct before your first quarter, and if you aren't sure whether a tool is allowed, check with ABIM first.
Timing, Feedback and the Final Decision
LKA pacing: Each question allows five minutes, with a bank of 30 extra minutes each year for the ones that need longer. ABIM's LKA infographic reports that physicians spend under two minutes per question and under an hour per quarter on average. You can answer a few questions at a time or all 30 at once, but any question you don't open by the end of the quarter expires and counts against the 100 you may leave unopened over five years.
LKA feedback: After each answer, you see whether you were right, with a rationale and references, and each correct answer earns 0.2 MOC points. From the second year, quarterly progress reports show how you're doing against the passing standard. The pass/fail decision comes once, at the end of the five-year cycle.
If you don't pass: A single unsuccessful attempt doesn't by itself end your certification, as long as you meet the other MOC requirements. You enter a grace year and have until the end of that calendar year to pass the 10-year exam.
The biggest LKA risk is participation. ABIM's 2025 report found that every physician who entered the grace year through the LKA did so because they missed the annual participation requirement. Plan around expiring questions.
Which Option Fits You?
- The LKA tends to suit you if you'd rather spread the work out, learn well from immediate feedback, and want to answer questions from home or between clinic sessions. It's also the more common choice: in ABIM's 2025 report, most certificates that met the assessment requirement did so through the LKA.
- The 10-year exam tends to suit you if you prefer one concentrated review period to five years of quarterly deadlines, or if your schedule makes steady participation hard to count on.
- Either way, plan ahead. You need to pass or begin an assessment starting in your assessment due year, so check your options in your ABIM Physician Portal well before then.
How to Prepare for Each
1. For the LKA, build a quarterly routine:
- Put each quarter's end date in your calendar, with a reminder two weeks before.
- Answer a few questions each week instead of all 30 in the last days of the quarter.
- Set up your go-to references before you start, so a lookup takes seconds.
- Read every rationale, including those for questions you got right, and note the topics you missed.
- From year two, let your progress reports point your reading at your weakest categories.
2. For the 10-year exam, plan a focused review:
- Weight your time by the blueprint, starting with cardiovascular disease and the 10% categories.
- Prioritize areas where practice has changed in recent years, since the blueprint emphasizes them.
- Work timed, mixed blocks to rebuild test-day stamina, and review every miss for the reasoning, not just the fact.
- Rehearse quick lookups so UpToDate saves you time instead of eating it.
- If you work mostly in the hospital, give office-based topics extra time, or look into the Internal Medicine: Inpatient version.
How MedMatrix Can Help
- LKA-pace practice sets: 30 questions at five minutes each, with the answer and explanation after every question, so you can rehearse the rhythm between quarters. They're for practice only: ABIM's code of conduct bars copying or sharing live LKA questions, so never bring those into MedMatrix or any other tool.
- An ABIM-style question bank mapped to the blueprint: Build sets by ABIM content category, and use the Missed and Flagged filters or "Auto-pick my weak areas" to focus on the categories your progress reports flag.
- Timed practice for the 10-year exam: Timed practice tests, plus a 240-question full-length simulation modeled on the Certification exam, help you rebuild stamina for a long exam day.
- Flashcards, podcasts, the AI Tutor and a lab values panel: Turn missed topics into spaced-repetition flashcards, review a topic as a podcast on your commute, ask the AI Tutor to explain a practice question, and check reference ranges as you work.
Neither path is easier; they're different shapes of the same work. Choose the one that fits how you practice and live, then build the routine that makes it automatic. Both aim at the same thing: showing yourself and your patients that your knowledge is current.
ABIM is a registered trademark of the American Board of Internal Medicine, which is not affiliated with MedMatrix and does not endorse it.