In early 2014, the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, and the American Association of Colleges of Osteopathic Medicine agreed to a memorandum of understanding describing a single accreditation system for graduate medical education in the United States. Although there are many benefits, such as consistent quality of graduate medical education, alignment of competency standards, alignment with policymakers' expectations, unification of voices on graduate medical education access and funding issues, and visibility of osteopathic medicine, there are also many challenges in creating a uniform system of graduate medical education. The authors review the pathways to initial certification for both the American Board of Surgery and the American Osteopathic Board of Surgery and discuss recertification and maintenance of certification.