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Pediatric subspecialists in academic medicine earn less than adult subspecialists, but whether this disparity has changed over time is unclear. We compared the net present value (NPV) of lifetime earnings between pediatric and adult subspecialists in 2014 and 2024 and evaluated changes in the relative earnings differential. We conducted a retrospective economic analysis using Association of American Medical Colleges Faculty Salary Reports from 2014 and 2024. Salaries at the 25th, 50th, and 75th percentiles were extracted across academic ranks for pediatric and adult subspecialties and converted to 2024 dollars. Lifetime earnings were modeled through retirement at age 67 using a 3% real discount rate and three promotion pathways (baseline, plateaued, and no promotion). The relative earnings differential was defined as (Adult NPV - Pediatrics NPV)/Pediatrics NPV × 100. Across subspecialties, adult subspecialists in academic medicine had higher lifetime NPVs than pediatric subspecialists in both years. In 2024, lifetime NPVs for pediatric subspecialists ranged from $4.9 million to $7.6 million, compared with $5.3 million to $9.4 million for adult counterparts (50th percentile, baseline promotion pathway). The average relative earnings differential widened from 15.7% in 2014 to 20.2% in 2024. Disparities were amplified at higher salary percentiles and with plateaued or absent promotion, reaching 41.5% in a no-promotion pathway at the 75th percentile. From 2014 to 2024, the lifetime earnings gap between pediatric and adult subspecialists in academic medicine widened, with potential implications for pediatric workforce sustainability.

The goal of the present study is to understand whether youth with Noonan Syndrome Spectrum Disorder (NSSD) are at increased risk of neurocognitive difficulties when living in resource depleted communities. Youth (5-17 years; Mage = 9.48 years) with NSSD (n = 140) and unaffected youth (4-15 years; Mage = 9.63 years; n = 85) were included. We ascertained the Child Opportunity Index Health and Environment Index (COI H/E) national-level Z-scores and assessed academic achievement and executive function. Multiple regressions were run to analyze the effects of diagnosis (whether the child had NSSD), COI H/E Z-scores, and diagnosis × COI H/E Z-score interaction on academic achievement (i.e., word reading, math, spelling, and sentence comprehension) and executive skills (i.e., performance-based working memory and processing speed and parent-rated measure of daily executive skills). Diagnosis was a significant predictor in each model. COI H/E Z-score was a significant predictor of spelling and a marginally significant predictor of sentence comprehension scores. There was a significant diagnosis × COI H/E Z-score interaction for working memory, and marginally significant interactions for spelling and sentence comprehension scores. Higher H/E Z-scores were associated with better working memory in the NSSD group and better academic achievement in the unaffected group. While the effects of NSSD are large on all assessed domains, there is an additional burden of resource depletion on working memory abilities of youth with NSSD. Academic achievement in the NSSD group was lower than the unaffected group across resource-depleted/enriched environments, demonstrating the profound effects of NSSD on academic functioning.

Advance care planning (ACP) is a vital tool to align patients' goals and values with their medical care; however, ACP has low completion rates. Barriers to ACP include lack of continuity across care settings, consistent documentation, electronic health record (EHR) accessibility to ACP information, and need for clinician education. To address these barriers, system-wide healthcare initiatives are needed. Examine a health system-wide approach to improve ACP completion and continuity among adult patients within an academic medical center. Retrospective cohort study PARTICIPANTS: A total of 34,268 patients aged 65 years or older receiving healthcare at a single academic medical center. A multimodal initiative across care settings (ambulatory, transition of care, and emergency department/hospital) was implemented to include patient cohort identification, EHR enhancements, addition of ACP dedicated social workers to enhance continuity, and clinician education. ACP completion was the primary outcome and defined as (1) completion of a Medical Orders for Life-Sustaining Treatment (MOLST) or Advance Healthcare Directive document, (2) identification of a surrogate decision maker, or (3) documentation of conversations regarding ACP goals. Fifty-one percent of the cohort completed ACP during the study (Feb. 2021-Jan. 2024). ACP completion likelihood increased among patients with a positive surprise question screen (adj IRR 4.56, [CI 3.52, 5.90]) and those diagnosed with dementia (adj IRR 1.59 [CI 1.47, 1.72]), advance cancer (adj IRR 1.37 [CI 1.19, 1.58], and heart failure (adj IRR 1.11 [Cl 1.04, 1.19]. Compared to baseline, ACP completion increased during both operational implementation periods: first period adj IRR 1.24 (CI 1.16, 1.32) and second period adj IRR 3.54 (CI 3.38, 3.70). This multipronged approach to a system-wide ACP implemented across care settings at an academic medical center led to an increase in ACP completion and provides a framework for other academic medical centers.

Physician-scientists represent one of the most impactful, yet underrecognized, innovations of 20th century academic medicine. Defined by a commitment to full-time careers in investigative work, physician-scientists have repeatedly demonstrated a unique ability to identify and solve problems of unmet medical need in a focused and intentional manner using their dual training in clinical medicine and the scientific method as both stethoscope and scalpel. Unfortunately, mounting financial pressures from both the clinical and research marketplaces have placed this storied workforce in jeopardy due to the absence of a dedicated and explicitly defined vocational structure and business model. This white paper reports the output of a consortium of academic medical centers, foundations and professional societies seeking to remedy this deficiency. This consortium specifically developed a framework to formalize the career path of physician-scientist faculty into a professionally unified and financially sustainable structure in a way that could be adopted to different U.S. academic medical centers and health systems. Key components of this framework included an administratively operational definition of physician-scientists, and three central and interconnected pillars (academic, financial, and organizational) that are rooted in this foundational definition. Herein, we detail core concepts and concrete recommendations.

Compensation for interventional cardiologists varies substantially by patient population and practice setting, yet no prior study has compared lifetime, discounted earnings between pediatric and adult interventional cardiology. Understanding these differences is essential for workforce sustainability and equitable access to congenital heart interventions. We conducted an economic evaluation using benchmark compensation and productivity data from pediatric academic, adult academic, and adult private. Lifetime earnings were estimated using a net present value (NPV) framework over a 32-year career (age 35-67) at a 3% discount rate (2025 USD). Models incorporated academic promotion scenarios, private-practice fixed and ramp-up structures, and a 10,000-iteration Monte Carlo simulation varying salary percentile, career length, and promotion timing. Productivity was assessed using daily relative value unit (RVU) and NPV per career RVU. At the 50th percentile, lifetime NPVs were $8.03 million for pediatric academic, $10.45 million for adult academic, and $15.73 million for adult private practice-gaps of 30% and 96% relative to pediatrics. Median Monte Carlo NPVs were similar ($7.81 million, $10.29 million, and $15.01 million, respectively). Pediatric interventionalists generated fewer daily RVUs (20.6) than adult academic (41.0) and adult private (43.0) cardiologists, whereas compensation per RVU was comparable. These disparities reflect lower achievable procedural throughput and occur within an RVU framework that has repeatedly under-recognized the time and intensity of congenital work. Limited private-practice opportunities in pediatrics further widen earnings gaps. Pediatric interventional cardiologists experience pronounced lifetime earnings disadvantages compared with adult counterparts because of throughput constraints, RVU valuation shortcomings, and labor-market structure. Addressing these systemic inequities will be essential to sustaining the congenital interventional workforce and ensuring equitable access to advanced cardiovascular care for children.

Children who survive critical illness commonly experience long-term morbidities. Little is known about the association of critical illness with cognitive health due to lack of preillness and postillness assessments and an adequate comparison population. To use school-based testing to evaluate cognitive health outcomes among children treated in the pediatric intensive care unit (PICU) compared with non-PICU-exposed control students. This retrospective case-control study used statewide academic data and propensity score matching of 1088 patients admitted to the only PICU in Arkansas from January 1, 2008, to December 31, 2018, as well as controls matched on sociodemographic and pre-PICU admission academic factors. Statistical analysis was performed from March 2024 to September 2025. PICU admission. Primary outcomes were (1) return to standardized testing, assessed using multivariable logistic regression to assess the odds of having a standardized test within 2 years after PICU admission compared with controls, and (2) change in pre-PICU to post-PICU test scores for PICU patients compared with propensity-matched control students, assessed using multivariable linear regression. In this case-control study of 1088 school-aged patients (mean [SD] age, 12.1 [1.6] years; 566 girls [52.0%]), fewer PICU patients than controls had test scores after admission for math (80.6% [874 of 1085] vs 86.5% [938 of 1085]; adjusted odds ratio [AOR], 0.64 [95% CI, 0.51-0.81]) and reading (81.1% [877 of 1081] vs 87.1% [941 of 1081]; AOR, 0.64 [95% CI, 0.51-0.82]). PICU patients' preadmission z scores were below average in math (z = -0.23 [95% CI, -0.29 to -0.16]) and reading (z = -0.22 [95% CI, -0.29 to -0.15]) compared with Arkansas students in the same grade and year. In adjusted pre-post analyses, PICU patients had a small but significant decrease in reading relative to controls (-0.07 [95% CI, -0.14 to -0.01]). The change in math score was not statistically significant (-0.06 [95% CI, -0.13 to 0.003]). This study suggests that PICU patients were less likely to take standardized tests after discharge and that those who did had greater decreases in reading scores relative to matched controls. Future studies should identify risk factors for nonreturn to testing and score decrease.

This second article in a series examines the contextual factors influencing the selection and use of standardized pediatric outcome measures (OMs) in physical therapist (PT) education and practice. Four focus groups were conducted with 32 participants, including pediatric PT faculty and clinicians. Data were analyzed using a constant comparative method and thematic analysis. Three major themes emerged: (1) curriculum selection, (2) practice selection, and (3) expectations of students. These themes were further divided into 11 categories and 32 subcategories, reflecting varied contextual influences such as institutional priorities, clinical demands, and perceptions of student readiness. Findings reveal the complex, context-dependent nature of OM decision-making and a persistent disconnect between academic and clinical practices. Understanding decision influencers is essential to improving alignment between educational preparation and clinical expectations, and to advancing evidence-based pediatric physical therapy practice.

Community-Based Participatory Research (CBPR) is grounded in trusting, reciprocal, and authentic relationships. We aimed to identify key strategies and actionable next steps to establish and sustain high-quality community-academic partnerships that foster community-based health equity. Qualitative thematic analysis. We analyzed three recorded discussions from a roundtable session with community and academic partners from the Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) program (2020-2025), which supported 142 community-engaged public health research projects aimed at reducing COVID-19-related health inequities. Key themes identified as most fundamental to support CBPR included establishing a long-term commitment, mutual co-learning among partners, flexible and sustained funding and resources, co-design of research and evaluation tools, and unwavering commitment to transparent communication and dissemination. Accurately assessing CBPR's impact requires using valid and reliable tools that assess whether community-academic partnerships are functioning well, identify opportunities to strengthen engagement, and measure both community- and system-level outcomes resulting from the partnerships. Advancing community-based health research through high-quality CBPR partnerships requires ongoing flexibility, mutual trust, shared learning, and collaborative design core elements to achieve sustainable and equitable public health outcomes. Through these initiatives we can pave the way for high-quality community-academic partnerships that address critical priorities in population health research and processes for advancing health equity.

Lumbar puncture (LP) remains a core emergency department (ED) procedure, though recent trends suggest a shift toward non-ED specialties. Within ED practice, trends in LP indications and procedural success are not well characterized. To evaluate longitudinal trends in LP procedural volume across departments within a tertiary care health system and to characterize trends in ED LP indications, success rates, and variables associated with success. We conducted a retrospective study at a single academic health system. LP volumes across clinical departments were assessed for calendar years (CYs) 2012-2024 using Poisson regression with incidence rate ratios (IRRs). ED-specific analyses included LPs performed from CYs 2014-2024, with temporal trends in indications evaluated using IRRs and multivariable logistic regression used to identify factors associated with LP success. Radiology performed the greatest number of LPs from 2012 to 2024, with a 4.4% annual increase (IRR 1.044, 95% CI 1.036-1.052). ED LP volume declined by 1.5% annually (IRR 0.985, 95% CI 0.972-0.999). A total of 1117 LPs were performed in the ED from 2014 to 2024 (mean 106 annually), with success decreasing from 93.1% to 76.3%. LPs for subarachnoid hemorrhage declined (IRR 0.78/year, p&#xa0;<&#xa0;0.001), while those for idiopathic intracranial hypertension (IIH) increased (IRR 1.29/year, p&#xa0;<&#xa0;0.001). Upright positioning was independently associated with higher odds of success compared with lateral decubitus (OR 2.2, 95% CI 1.2-4.0). LP volume shifted toward non-ED specialties, particularly Radiology, Internal Medicine, and Pediatrics. Within ED LP practice, indications shifted toward IIH and upright positioning was associated with greater LP procedural success.

This report describes the process of collage creation designed for Michigan Youth Health (MYHealth) students to generate and prioritize research topics related to adolescent health and wellness challenges. MYHealth is a youth-partnered research training program grounded in youth participatory action research methods and designed to encourage high school students to explore STEM (Science, Technology, Engineering and Mathematics) and health research fields. Within the MYHealth program, students partner with academic health researchers to conduct their own research projects on an adolescent health topic. During the initial training, MYHealth students identify possible research topics that form the basis for research they conduct throughout the academic year. Integrating elements of arts-based, participatory, and narrative research methods, a collage creation process was used to stimulate, generate and prioritize research topics for future planned research with students. We detail the collage creation process and provide three illustrative examples of students' collages and how the collages helped students generate and prioritize research topics. We conclude with student reflections on the collage creation process and lessons learned regarding the successful use of this method to engage high school students in STEM and health research and to identify relevant research topics in a youth research education program.

Type 1 diabetes (T1D) complications may impair cognitive development, but evidence on cognitive skills in children and adolescents with T1D is inconsistent. This study aimed to document measures and outcomes used to assess cognitive skills in children with T1D and to examine the relationship between T1D and cognitive skills. A systematic literature search was conducted across five databases to identify studies that administered cognitive assessments to children and adolescents aged &#x2264;19 years with T1D. Study characteristics, cognitive skills assessments and outcomes and comparisons to non-T1D peers where available were synthesized on an evidence map. Random-effects meta-analysis was used to assess differences in Wechsler Full Scale Intelligence Quotient (IQ) test scores between T1D and non-T1D groups. From 2464 studies, 129 were included. Five main cognitive categories were identified, with comparisons to non-T1D peers-where available-yielding mixed results: academic performance (n=37; n=7/22 worse T1D), executive function (n=101; n=31/48 worse T1D), intelligence (n=73; n=22/37 worse T1D), language (n=30; n=7/20 worse T1D) and memory and learning (n=84; n=31/48 worse T1D). Large-scale studies (n&#x2265;1000) did not find significant differences between groups for academic performance (n=0/6 worse T1D) and language (n=0/3 worse T1D). In the meta-analysis of 16 studies (n=1594), children with T1D had slightly lower IQ scores than peers without T1D (mean difference -3.49, 95%&#x2009;CI (-6.16 to -0.82); p=0.010). T1D appears to be associated with slightly lower cognitive outcomes in some areas. Further research is needed to understand the impact of these findings on daily functioning and to inform screening for at-risk children.

Addressing etiological and maintaining factors at play in psychopathology is essential for appropriate treatment of symptoms and development of healthy skills. Emotion regulation (ER) is one such factor associated with developmental, familial, social, and academic wellbeing. Autistic youth demonstrate increased difficulties with emotion regulation, which may contribute to several commonly cooccurring psychiatric concerns observed in autism. Despite an increased risk, few interventions target emotion regulation specifically in autistic populations. Importantly, autistic youth may present unique strengths and challenges related to emotion processing, regulatory strategies, and skill building. The goal of this paper is to share clinical perspectives derived from implementation of Regulating Together (RT), a manualized group intervention targeting emotion regulation difficulties in autistic youth, and to use examples from RT to illustrate how ER interventions can address common challenges and draw upon strengths observed in this population. Here, we outline several of these strengths and challenges related to ER difficulties found in the literature and clinical perspectives informed by caregiver reported observations. RT is presented as a model to inform ER intervention approaches to address these challenges and utilize strengths.

Competency in the pediatric genital examination is critical, but physician comfort and ability are often limited. Contributing factors include lack of standardized teaching, inconsistent training, and the examination's sensitive nature. These gaps may lead to missed signs of abuse or misinterpreted findings. A trauma-informed approach emphasizing patient safety, empowerment, and healing may help address these challenges. We conducted a qualitative study to explore pediatricians' experiences and identify barriers, facilitators, and recommendations. We interviewed 7 pediatricians in an ambulatory setting at an academic hospital in New York City. Data were analyzed thematically, with transcripts coded by the research team. Themes focused on provider experiences, barriers, and recommendations. Barriers included limited training, time constraints, discomfort, and fear of causing trauma. Pediatricians suggested building rapport, empowering patients, standardizing examinations, and ensuring cultural sensitivity. Trauma-informed strategies may improve provider comfort, examination frequency, and patient care.

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that begins in childhood and may persist into adulthood, characterized by inattention, impulsivity, and hyperactivity leading to functional impairment. The global prevalence in children and adolescents ranges from 5-7%, yet data from the Eastern Province of Saudi Arabia remain limited. This study determined the prevalence of hyperactive/impulsive and inattentive symptoms among children and adolescents aged 4-18 years and identified associated factors. A cross-sectional study was conducted across major cities using validated Arabic versions of the SNAP-IV and NICHQ Vanderbilt Assessment Scale distributed online. The survey assessed ADHD symptoms, oppositional defiant disorder, conduct disorder, anxiety/depression, functional impairment, and prenatal and perinatal risk factors, with DSM-based scoring and multivariable logistic regression to identify predictors. Among 920 participants (mean age 10.7 years; 52.9% boys), 12.7% met criteria for ADHD. The inattentive subtype was most common, followed by combined and hyperactive/impulsive types. Affected children and adolescents showed academic and interpersonal difficulties. Significant predictors included younger age, birth weight <1.5 kg, psychiatric history, previous ADHD diagnosis, and family history of psychiatric or neurological disorders. ADHD symptoms were relatively common and associated with functional impairment and identifiable developmental and familial risk factors.

University students are at a key life stage in their lives for the development of health-related behaviors, yet few studies have explored their overall lifestyle using multidimensional tools. The present exploratory study aimed to assess lifestyle through the Short Multidimensional Inventory Lifestyle Evaluation for University Students (U-SMILE) and to determine its sociodemographic and health correlates in a sample of Spanish university students. This cross-sectional analysis was based on baseline data collected at Universidad Loyola Andaluc&#xed;a (Spain) as part of the UNIversity students' LIFEstyle behaviors and Mental health (UNILIFE-M) multicenter project during the 2024 academic year. A total of 671 first-year students (median age&#x2009;=&#x2009;18 years, 50.1% female) completed validated self-report questionnaires assessing lifestyle behaviors, sociodemographic variables, body mass index (BMI), and diagnosed health conditions. Lifestyle was evaluated using the U-SMILE. Descriptive statistics and robust linear models were applied to identify associated factors. The median overall U-SMILE score was 69.0 points (interquartile range [IQR]&#x2009;=&#x2009;64-73). Older students (>&#x2009;18 years old) presented lower scores (unstandardized beta coefficient [B]&#x2009;=&#x2009;-1.59; p&#x2009;=&#x2009;0.006), as did those enrolled in non-health science degrees (B = -1.47; p&#x2009;=&#x2009;0.005), single students (B =-1.40; p&#x2009;=&#x2009;0.013), and those with a mental disorder (B = -2.79; p&#x2009;=&#x2009;0.001). Heterosexual students scored higher than non-heterosexual peers (B&#x2009;=&#x2009;2.49; p&#x2009;=&#x2009;0.007), and students with normal weight showed better results than underweight participants (B&#x2009;=&#x2009;2.08; p&#x2009;=&#x2009;0.020). Domain-specific analyses revealed that males scored higher in physical activity, sleep, and social support, whereas females performed better in stress management. Students residing outside university accommodation generally achieved higher domain scores. These exploratory findings suggest that lifestyle, as measured by the U-SMILE, is associated with several sociodemographic and health-related characteristics in Spanish university students. Lower scores were associated with older age, enrolment in non-health science degrees, underweight status, non-heterosexual orientation, single marital status, and the presence of a diagnosed mental disorder. Sex, BMI status, accommodation, and employment status were associated with specific lifestyle domains.

We present the case of an immunocompetent, fully vaccinated 17-year-old female who developed severe, disseminated varicella-zoster virus (VZV) reactivation with visceral involvement, Ramsay Hunt Syndrome, and complications of suspected superimposed bacterial cellulitis, chronic pain, as well as postherpetic neuralgia. We aim to highlight the importance of early recognition and multidisciplinary management of varicella-zoster virus in immunocompetent patients to minimize disease complications. All data were obtained from the electronic medical record with permission from the patient and her parent. The patient underwent serial dermatologic examinations and a comprehensive immunologic workup. Positive VZV PCR testing of the lesion and blood confirmed active VZV infection. Despite an intensive multi-drug antiviral regimen, she developed suspected clinical drug resistance-although resistance testing was not performed-progressing to disseminated varicella with hepatic involvement. Inpatient complications included Ramsay Hunt Syndrome, suspected superimposed bacterial cellulitis, opioid withdrawal, and chronic pain. While outpatient, she developed postherpetic neuralgia and psychosocial impairment, preventing her from completing her academic year. This case illustrates a rare, but severe presentation of disseminated varicella-zoster virus with visceral involvement and concomitant Ramsay Hunt Syndrome in a healthy adolescent. It underscores the importance of considering VZV in the differential diagnosis of pediatric rash and neuropathy in all patients, irrespective of immune status.

Background: Prolonged boarding of patients in the pediatric emergency department (PED) is associated with increased risk of missed or delayed administration of essential home medications. Children with chronic medical or psychiatric conditions requiring time-sensitive medications may experience preventable clinical deterioration during extended PED stays. The aim was to increase the percentage of encounters in which all high-risk home medications were ordered for pediatric patients roomed in the PED >4 hours from 38% to over 70% between August 2024 and June 2026.Methods: We conducted a quality improvement initiative at a large, academic PED. Eligible patients were &#x2264;18 years, remained in the PED for >4 hours after rooming, and were anticipated to require admission. Using Model for Improvement and Lean methodology, we implemented workflow-integrated interventions, including division-wide education, caregiver-integrated medication identification via electronic triage, time-based electronic reminders, and workflow-embedded ordering tools. The primary outcome was the proportion of encounters in which all high-risk home medications were ordered. Data were analyzed using statistical process control charts.Results: In association with our improvement interventions, the average percent of encounters for boarding patients in which all high-risk home medications were ordered increased from a baseline of 38% to 87% with special cause variation observed on a statistical process control p-chart.Conclusions: A multifaceted, workflow-integrated quality improvement initiative was associated with improved reliable ordering of high-risk home medications for boarded pediatric patients. Embedding medication identification and ordering supports within clinical workflows represents a scalable strategy to improve medication safety during prolonged PED stays.

Pregnancy in adolescence disrupts education, perpetuates economic dependence, and contributes to repeated cycles of poverty. Romania continues to report high adolescent birth rates within the European Union. We evaluated changes in adolescent socioeconomic profiles, perinatal care patterns, and early neonatal outcomes in a Romanian public academic maternity hospital between two snapshots taken ten years apart. We conducted a retrospective repeated cross-sectional study of 2237 mother-newborn dyads from two periods: 2011-2012 and 2022-2023. Adolescents (<20 years) were compared with adults aged 25-29 years. The outcomes were delivery mode, preterm birth, low birth weight, small for gestational age (SGA), 5-Apgar score <7, Neonatal Intensive Care Unit (NICU) admission, and breastfeeding initiation. Multivariable logistic models included age group, time period, and their interaction, adjusting for education, antenatal care, and parity. In 2022-2023, adolescent pregnancy was associated with decreased odds of cesarean delivery (OR 0.34, 95% CI 0.26-0.46), SGA (OR 1.76, 95% CI 1.1-2.93), and NICU admission (OR 2.31, 95%CI 1.56-3.01). Breastfeeding initiation declined over time and was less likely among adolescents in the newer period (OR 0.49, 95% CI 0.29-0.84). Despite improved antenatal care, education and reduced early marriage/cohabiting, adolescents continued to experience higher-risk neonatal outcomes over the past decade. Implementing interventions that strengthen social determinants of health and expand postpartum support is essential.

In 2022, Step 1 of the United States Medical Licensing Examination transitioned to pass/fail scoring, removing a major performance-oriented incentive that historically shaped how and why students prepared for the exam. While Step 1 is typically taken before clerkships, some medical schools have shifted the exam to after core clerkships, citing potential benefits for learning and integration. This study examined whether the timing of Step 1 continues to influence performance outcomes in the pass/fail era, using achievement goal theory and self-determination theory as conceptual lenses. Achievement goal theory distinguishes among mastery-approach, performance-approach, and performance-avoidance goals that fluctuate across contexts; self-determination theory emphasizes how assessment environments support autonomous versus controlled forms of motivation. This study compared outcomes at 20&#x2009;US medical schools that administered Step 1 after clerkships to those at a matched group of schools that administered the exam pre-clerkships. All students matriculated in 2020 and took Step 1 on or after January 26, 2022, when pass/fail scoring began. We matched schools based on average Medical College Admission Test (MCAT) scores to help control for incoming academic ability. We used a resampling procedure with 10,000 replications to estimate average differences in Step 1 and Step 2 Clinical Knowledge (CK) failure rates and scores. Compared to matched pre-clerkship schools, post-clerkship schools had a slightly lower Step 1 failure rate (mean difference: 1.02%, SD = 0.89, CI = 1.00-1.04%). In contrast, Step 2 CK outcomes modestly favored pre-clerkship schools: failure rates were 0.39% lower (SD = 0.21, CI = 0.39-0.4%) and scores were 1.03 points higher (SD = 0.53, CI = 1.02-1.04%) on average. Across all outcomes, differences were small and unlikely to be educationally meaningful. Among students at post-clerkship schools, a shorter interval between Step 1 and Step 2 CK was associated with slightly higher Step 2 CK scores for students with lower MCAT scores, whereas the interval had little impact for students with higher MCAT scores. In the pass/fail context, the timing of Step 1, before or after clerkships, appears to have minimal influence on performance outcomes. These findings suggest that changes to Step 1 scoring and timing alone are unlikely to shift learner behavior; broader assessment and curricular reforms that intentionally foster autonomous, mastery-oriented learning may be needed to support deep learning, well-being, and readiness for practice.