This commentary reviews the trends of pass rates for certification and recertification in internal medicine. This is true for certification since the 1930s and recertification since 2000. Predictors of performance, such as program director ratings and the in-training examination, are discussed in addition to positive clinical outcomes in relation to recertification. Differences in examinations pass rates due to gender, geographic location and number of attempts are reviewed. Recent trends in internal medicine demonstrate a decline, which may be multifactorial in reasoning. This is not unique to internal medicine as declines in certification rates have been noted in general surgery as well. Methods of preparing for the examination are discussed to maximize performance on the examination.