Purpose Competing risk methodology was used to identify variables associated with promotion and attrition of newly appointed full-Time instructors or assistant professors in U.S. MD-granting medical schools. Method A national sample of U.S. MD-granting medical school graduates in calendar years 1997-2004 who received initial full-Time instructor or assistant professor appointments from January 1, 2000 through December 31, 2012, was followed through December 31, 2013. Adjusted proportional subdistribution hazard ratios (aSHRs) measured the effects of demographic, educational, and institutional variables on promotion and attrition. Results The final study sample included 27,219 full-Time instructors (n = 10,470) and assistant professors (n = 16,749). In all models (entire sample and stratified by initial rank), faculty who reported all other (vs. full-Time faculty) career intentions at graduation and were underrepresented racial/ethnic minority (vs. white) faculty had lower aSHRs for promotion and greater aSHRs for attrition, whereas research-intensive (vs. non-research-intensive) medical school graduates, faculty at schools without a tenure track, and mentored K awardees had greater aSHRs for promotion and lower aSHRs for attrition. In all models, faculty with ≥ $100,000 (vs. no) debt at graduation had greater aSHRs for attrition. Among instructors, women had lower aSHRs for attrition than men, but among assistant professors, women had greater aSHRs for attrition. Conclusions This study adds new knowledge about career trajectories of academic medicine faculty initially appointed as full-Time instructors. Career development interventions and research mentoring during and after medical school and debt reduction programs could help increase academic medicine faculty retention and promotion.