Academic tenure is the guarantee that a faculty member cannot be arbitrarily dismissed. The tenure system developed to maintain academics free of external pressure and coercion, and in dramatic instances tenure has been used to defend academic freedom. With the development of the research-oriented medical school staffed by full-time faculty, the reward system of tenure and promotion was grafted on to academic medicine. The changing face of academic clinical medicine places significant stresses on the traditional tenure system and raises the question of whether it is fundamentally irrelevant. Tenure has been defended as the protector of free inquiry, insurer of academic excellence, contributor to research and its benefits to society, and a means of selecting the best and brightest for our faculties. Tenure has been criticized as a contributor to academic sloth, codifier of gender and racial discrimination, and as a system unable to deal with the economic realities of high-priced referral specialties. As academic medical centers increase their efforts at clinical outreach, it is unclear whether traditional promotion and tenure will be of interest to clinicians employed solely to deliver primary care. In this special report, I review the history of tenure, arguments for and against its use for clinicians, and proposals for reform.