Academic General and Subspecialty Pediatric Promotion Timelines and Lifetime Earnings.

Importance: Differences in academic promotion timelines may contribute to long-standing disparities in pediatric physician compensation and impact workforce sustainability. Objective: To evaluate the association between promotion timing and the net present value (NPV) of lifetime earnings for academic general pediatricians and pediatric subspecialists across salary percentiles and career lengths. Design, Setting, and Participants: This cross-sectional study using a financial modeling strategy examined 2024-2025 compensation data from the Association of Administrators in Academic Pediatrics. The NPV analysis was conducted for 29 pediatric fields across 4 promotion scenarios (early promotion, baseline promotion, stalled promotion, and no promotion), 3 salary percentiles (25th, 50th, and 75th), and 3 career lengths (standard, part time, and early retirement). Exposure: Promotion timeline and pediatric subspecialty. Main Outcome and Measures: The outcome was NPV of lifetime earnings as measured in constant 2025 dollars. Results: A total of 19 111 academic pediatricians and pediatric subspecialists were included from the compensation dataset. Early promotion consistently yielded the highest NPV across all subspecialties and salary percentiles (median NPV, $7 621 223.50), while remaining at the assistant professor rank for an entire career was associated with the lowest NPV (median, $6 967 428.72). Baseline promotion NPV peaked at a mean (SD) of $9 364 986.25 ($695 347.50), while no promotion NPV was significantly lower (mean [SD], $7 093 248.02 [$475 237.71]). Stalled promotion reduced the median NPV by $500 000 to $1.5 million; no promotion led to losses exceeding $2 million to $3 million in high-paying subspecialties, such as cardiology, critical care, and neonatology. Sensitivity analyses and Monte Carlo simulations found that delayed promotion was negatively associated with lifetime earnings under all tested scenarios. Conclusions and Relevance: In this cross-sectional study of academic pediatricians, promotion timing was associated with lifetime earnings and often more influential than subspecialty or salary percentile. The findings suggest that physicians who were never promoted may need to work an additional 10 years to match the earnings of peers promoted via a baseline promotion trajectory. The findings highlight the financial consequences of delayed advancement and underscore the need for institutional efforts to support timely and equitable promotion across the pediatric workforce.