Tenure has been the dominant influence on systems of academic promotion and remains important in medical schools, despite the growing prevalence of non-tenure academic tracks. Although the number of clinician faculty members currently choosing tenure track has dropped dramatically, tenure may be an appropriate career path for individuals, and understanding tenure can help all faculty members navigate promotion systems. National trends show medical schools making modest adjustments to allow greater flexibility in tenure policies especially concerning the probationary period and the availability of tenure for part-time faculty members. Nevertheless, tenure regulations remain highly structured and inflexible. Achieving tenure requires careful planning, monitoring of progress, and optimizing resources, both within the home academic department and elsewhere. Once achieved, tenure guarantees a faculty position but does not guarantee resources, specific roles, or responsibilities and may not guarantee salary. Tenured faculty members can only be dismissed for serious specific reasons and after implementation of a strictly-defined process.