The preprint ecosystem has expanded rapidly over the past decade, fundamentally altering science communication. Yet, the scholarly community’s attitudes toward this shift remain underexplored. Through a large-scale survey of US and Canadian biomedical scholars, we provide a comprehensive analysis of preprint utilization, perceived impact, and integration into academic credit systems. We find robust engagement across reading, citing, and submitting preprints; however, this activity is driven primarily by a desire for rapid dissemination rather than a foundational commitment to open science. Furthermore, while preprints are valued as networking assets, perceived career penalties during formal academic evaluations stifle broader cultural adoption. Crucially, to navigate the absence of formal peer review, scholars report a heavy reliance on author reputation as a primary heuristic for evaluating a preprint’s credibility and guiding their reading and citation decisions. Notably, despite acknowledging preprints’ role in accelerating knowledge sharing, scholars express significant concerns regarding fraud and misinformation, particularly amid declining public trust in science and emerging threats to scientific integrity from artificial intelligence. To resolve these tensions, the preprint ecosystem must evolve beyond prioritizing speed to foster genuine academic dialogue. Simultaneously, evaluation frameworks must adapt to the realities of preprinting, and innovative quality-control mechanisms are urgently needed to balance rapid dissemination with rigorous scientific integrity.