From Parallel to Aligned: A United States Medical Licensing Examination (USMLE®) Mapping and Assessment-Tagging Framework for Medical Education

From Parallel to Aligned: A United States Medical Licensing Examination (USMLE®) Mapping and Assessment-Tagging Framework for Medical Education | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Parallel to Aligned: A United States Medical Licensing Examination (USMLE®) Mapping and Assessment-Tagging Framework for Medical Education Robert M. Badeau, Thea Mallini, Jennifer Laury, Vincent VanBuren, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7850561/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Medical students often experience a “parallel curriculum,” which is perceived or a real misalignment between what is taught in the formal institutional curriculum and, for licensing, the United States Medical Licensing Examination (USMLE®) content that they must master independently. By delivering transparency to the faculty and students, curriculum mapping institutional curriculum objectives and assessments to USMLE® content can reduce this perception by showing the scope and sequence of board-relevant topics through dashboards and the connected assessments. Methods To align USMLE® content to our curriculum, we developed and operationalized a granular, machine‑readable coding library derived from the 2025 USMLE® Content Outline (STEP) and to demonstrate its utility for session‑level mapping and assessment tagging. Results Using a top‑down, left‑to‑right parse of the STEP, we constructed a hierarchical code library with the parent–child relationships preserved. “Normal processes” were assigned 1.0 codes within each system to distinguish physiology/anatomy from pathology. We then used a structured prompt with a generative AI assistant to propose STEP codes for preclerkship session-level learning objectives. The library spans 18 STEP domains and supports alignment at multiple levels of granularity. Early use cases include ( 1 ) session‑level mapping to surface gaps and redundancies and ( 2 ) assessment tagging to enable exam blueprinting by STEP domain. Conclusions To mitigate the “parallel curriculum,” these linked STEP codes can, in the future, be visualized at a course- or phase-level to provide faculty and students linkages between session-level course objectives and assessments to STEP. This coding library is generalizable across courses, phases, and external institutions and can be mapped by AI technologies. assessment tagging curriculum mapping learning objectives exam blueprinting ontology codebook undergraduate medical education united states medical licensing examination Figures Figure 1 Figure 2 Figure 3 Background In many medical schools, students perceive that two curricula exist in “parallel” being the institutional curriculum that is formally taught and assessed, and the 2025 USMLE® Content Outline (STEP) that students must master independently and is self-directed (Burk-Rafel, J., et al. 2017, Geraghty, J.R. et al. 2023).This perception may increase student apprehension in choosing their study planning. For example, they may be required to study a large amount of mandatory content for their courses that is unrelated to STEP, and the additional workload may have a negative impact on performance and their overall wellbeing (Baniadam, K. et al., 2023, Burk-Rafel, J., et al. 2017, Geraghty, J.R. et al., 2023, Tackett et al., 2022). This perceived duality highlights the value of linking STEP directly to the institutional curriculum, especially to learning objectives and assessments. Doing so offers faculty and students a benchmark to understand where STEP topics are addressed and to realign their course instructional design to bridge coverage and sequence gaps and reduce redundancy. Providing these linkages through visualization, such as in dashboards, allows stakeholders to evaluate alignment and make intentional choices to strengthen connections between institutional objectives, STEP, and assessments (Harden, 2001, Al-Eyd, 2018). Curriculum mapping plays a major role in curriculum development and planning and, overall, in the quality improvement process by forming relational linkages among institutional program objectives, course-level learning objectives, session-level learning objectives while allowing alignment with frameworks such as the AAMC Keywords and STEP (Harden, 2001; Al-Eyd et al., 2018, Prideaux, and Ugidama). These relational linkages can be visualized to the institutional stakeholders that may increase positive perceptions in alignment and intentionality. This alignment is facilitated by “tagging” curricular content, such as assessments, to STEP and AAMC Keywords, that allows for aggregated data summation, curation, and visualization. Although not directly intended to reduce the perception of a "parallel” curriculum and lacking an intentional coding system, approaches to map STEP to curricular elements exist. Dexter et al. (2012) developed an approach that deconstructed the STEP outline into Medical Subject Headings (MeSH) terms for use in their database, while Yoder et al. (2024) demonstrated how student-generated learning objectives could be mapped against STEP. In these studies, STEP is not formally coded or presented at a granular level that limits the standardization, depth, and utility in categorizing institutional STEP content and setting STEP benchmarks for curricular content development. STEP is granular at multiple levels that can create complexity, especially in MeSH term searching. Currently, coded AAMC Keywords offer a solution to standardizing curriculum content through tagging, however, these Keywords offer broad and simple medical and basic science terms that are not granular and require additional searching to find medical content definitions and are not directly connected to STEP. Currently, due to a perceived parallel curriculum, solutions in searching, collection, and visualization of standardized, granular STEP data content and related relational linkages are needed by medical school curriculum stakeholders to make effective decisions in planning a STEP-aligned curricular design. With an effective curricular map that is aligned to STEP, faculty and students can easily understand how the institution’s curriculum aligns with STEP and that mitigates negative student perceptions about an institution’s perceived ignorance of Step 1. Here, we describe how these codes are operationalized and show their role in bridging institutional learning objectives with STEP to align in-house curricular design to STEP, thus reducing the perception of a “parallel” curriculum. We created a machine-readable, granular, hierarchical coding library that was built from STEP. We have used these STEP codes to tag or link preclerkship session learning objectives and exam questions. To the best of our understanding, there exists no similar methods. Methods USMLE ® Content Outline As our reference, we used the 2025 USMLE Content Outline: https://www.usmle.org/sites/default/files/2022-01/USMLE_Content_Outline_0.pdf Code Library We created a hierarchical coding library by a top-down, left-to-right method in transferring data from the USMLE Content Outline to an Office 365 Microsoft Excel spreadsheet. The major Content Topic was the parent and from each bullet point downward, we assigned “2.1” as the first code. If there was another bullet point that had more than one description, then we created “2.1.1” etc. For “normal” processes, we created our in-house code as “1.0.” This was machine-readable and granular. Curriculum Linking to Session Learning Objectives We used ChatGPT 5 to generate matches between session learning objectives in preclerkship curriculum with the prompt: “I am a curriculum analyst at a medical school. I need to map USLME Step Codes to Session Learning Objectives. I need all the codes that are linked to that session learning objective in column c of the CV worksheet (CV Step practice). The master code library (USMLE Codes Library).” Exam Tagging Using the ExamSoft Enterprise Portal (www.examsoft.com), in “Category Management” in the “ADMIN” drop-down menu, we created a “MED - 2024 USMLE STEP Codes” category. We created 18 categories for each STEP Content title. These categories were then available upon editing an exam question. Results A hierarchical, machine-readable STEP coding library was developed from the 2025 integrated USMLE® Content Outline. Each code retained its parent–child relationship within the outline that enabled alignment at both broad and granular levels. This coding library had 18 USMLE® Content Outline Content topics (Table 1). Table 1. USMLE® Content Outline Content topics 2025 USMLE® Content Outline Content topics Human Development Gastrointestinal System Immune System Renal and Urinary System Blood and Lymphoreticular System Pregnancy, Childbirth, and the Puerperium Behavioral Health Female and Transgender Reproductive System Nervous System and Special Senses Male and Transgender Reproductive System Skin and Subcutaneous Tissue Endocrine System Musculoskeletal System Multisystem Processes and Disorders Cardiovascular System Biostatistics, Epidemiology/Population Health, and Interpretation of the Medical Literature Respiratory System Social Sciences From these Content Topics, a hierarchical structure was built with the major STEP topic as the parent. We used Microsoft Excel in a 2-column format to provide a machine-readable form. Reaching granular levels, based on the USMLE Content Outline, Figure 1 shows an example of the 2025 USMLE® Content with the Cardiovascular System Content Outline (1 A) and our coded library (1 B). From top down, codes were created in-house that went from 2.1 Infectious and immunologic, including microbiologic and host response to insult to 2.1.1 Infectious disorders: bacterial endocarditis, myocarditis based on the tabulated structure in the Content Outline. To account for normal conditions, for instance, in “normal” anatomy content, we created a 1.0 code that was linked to normal processes and, in this case, “ CS 1.0 Cardiovascular System: Normal Processes.” To demonstrate granularity, the coding for “Skin & Subcutaneous Tissue” is shown (1 B). From highest to lowest, ST 2.1 Infectious, immunologic, and inflammatory disorders, including microbiologic and host response to insult > ST 2.1.1 Infectious disorders and infestations > ST 2.1.1.1 Bacterial: cellulitis, erysipelas, impetigo, staphylococcal scalded skin syndrome; abscess, cutaneous, including septic abscess; anthrax (Bacillus anthracis); carbuncle; folliculitis; pilonidal cyst, infected; MSSA and MRSA skin infections; mycobacterial infections (e.g., leprosy, draining sinus); scarlet fever (group A Streptococcus). Using these codes, we have used the ChatGPT 5 generative AI tool to map them to our session learning objectives at multiple hierarchical levels. After the automated coding, we reviewed the linkages for accuracy. Figure 2 shows an example of STEP-coded Session Learning Objectives for the Cardiovascular System Organ Block in our preclerkship curriculum. To tag our in-house preclerkship exams, in ExamSoft, we added a STEP catagory that contained our STEP codes. Figure 3 shows an example of the operationalization of the STEP codes. Discussion Here, to the best of our knowledge, we show the operationalization of STEP through a machine-readable, hierarchical coding library. We show how these codes can be mapped to session-level learning objectives and to exam questions. This innovation’s utility comes through data collection and visualization. A challenge that we have at our medical institution is that students perceive that our curriculum is “disjointed,” and this reduces confidence that they will be prepared for their Step 1 exam. Students use third-party resources for studying and may not attend lectures and may not reach their potential on in-house exams leading to dissatisfaction. To provide a solution, we collect session-level learning objectives from our courses each academic year and have linked STEP codes to these. We are also mapping these STEP codes to our in-house exams. We have started to do semantic mapping with these codes and session-level learning objectives to visualize the coverage of STEP in our curriculum. For transparency and intentionality, we intend to share these dashboards with faculty and students. According to the USMLE Step 1 Content Outline and Specifications, musculoskeletal, skin, and subcutaneous tissue account for approximately 8–12% of total questions, and the gastrointestinal system accounts for 6–10% (United States Medical Licensing Examination [USMLE], n.d.). It is possible to create dashboards of respectively covered content from the USMLE “tags” that we have mapped to our session-level learning objectives and to assessment questions that support our exam blueprinting initiatives. Although we are in the process of creating semantic mapping visualizations and dashboards for these benchmarks, we can now communicate with curriculum stakeholders that we are effectively mapping our preclerkship curriculum to USMLE content. In addition, the machine-readability of the code data allows generative artificial intelligence platforms to align both relational and curricular inventory, with the possibility to create custom dashboards for the curriculum as a whole or cross-sectionally at each course. Furthermore, curricular relationships are easily understood by faculty and students with this standardized USMLE coding. A limitation to prior studies is in the USMLE data structure and subsequent reporting. By coding and linking USMLE content to session-level learning objectives or exam questions directly, these relationships are explicit. Prior studies did not address direct linkages of session-level learning objectives to USMLE content (Dexter et al., 2012; Yoder, 2024). To the best of our knowledge, the high-granularity coding that this method provides is original and can be used to provide multi-institutional benchmarking and a common coding framework similar to the existing AAMC Keyword library. A limitation in the AAMC Keyword library is its lack in granularity that can lead to a lack of clarity to faculty and other stakeholders. However, the AAMC Keyword library can give information on the Step 1 discipline specifications (United States Medical Licensing Examination [USMLE], n.d.). For example, 45 to 55% of the Step 1 discipline covered is pathology (United States Medical Licensing Examination [USMLE], n.d.). This can be mapped to keyword K-064 pathophysiology and when mapped to session-level objectives and also to assessment questions, the coverage in the curriculum can be determined. While the present study focused on building the STEP coding library, the system is designed to be adaptable. Institutions can use this method by session-level mapping, in assessment tagging, in gap and redundancy analysis, in multi-institutional benchmarking, and integration with existing frameworks. In session-level mapping, faculty can assign STEP codes directly to course and session objectives, creating a relational map between institutional objectives and STEP content. For example, a session on allergic asthma could be coded to both RS (Respiratory System: asthma, obstructive airway disease) and IS (Immune System: hypersensitivity reactions). With assessment tagging, exam questions can be linked to STEP codes, allowing institutions to generate item banks that align both with their curriculum and USMLE emphasis. This enables performance dashboards that display how students perform on specific STEP domains. In gap and redundancy analysis, institutions can compare which domains are overrepresented (e.g., Cardiovascular, Gastrointestinal) and which are underrepresented (e.g., Social Sciences, Patient Safety). This provides an evidence-based approach to refining curricular balance and constructive alignment. With multi-institutional benchmarking, because the code library is standardized and machine-readable, two or more schools could compare their mappings to the same STEP domains. This creates opportunities for shared benchmarking, collaborative research, and shared curricular innovation across institutions. In integration with existing frameworks, the STEP code library can be layered alongside the AAMC Keyword Library or institutional program objectives creating a unified database that supports our efforts in aligning our curriculum to STEP and shortening the gap in the “parallel curriculum.” Conclusions In conclusion, a granular, machine‑readable STEP code library operationalizes the 2025 USMLE Content Outline for curriculum mapping and assessment. The approach is generalizable across courses and institutions and lays the groundwork for multi‑institutional benchmarking, improved transparency for learners and faculty, and scalable analytics and visualizations that connect objectives and assessments. Abbreviations STEP 2025 USMLE® Content Outline USMLE United States Medical Licensing Examination AAMC Association of American Medical Colleges MeSH Medical Subject Headings CV Cardiovascular AI Artificial Intelligence Declarations Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Acknowledgements We wish to thank Dr. Kristy Motte, Ed.D. for her recommendations on improving this article and the Office of Academic Affairs team for resource support. Funding Not applicable. Authors’ contributions R.M.B wrote the manuscript with figures and tables, used the AI-Assistant, and did the exam tagging. T.M. created the coding library. J.L. and V.V. consulted and reviewed the manuscript. D.D. provided the resources to do this study. Ethics declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. References United States Medical Licensing Examination. USMLE® content outline. Federation of State Medical Boards & National Board of Medical Examiners. (2025). https://www.usmle.org/exam-resources/step-1-materials/step-1-content-outline-and-specifications Burk-Rafel J, Santen SA, Purkiss J: Study behaviors and USMLE Step 1 performance: Implications of a student self-directed parallel curriculum. Acad Med . 2017, 92:S67–S74. 10.1097/ACM.0000000000001916 Geraghty JR., Russel SM, Renaldy H, Thompson TM, Hirshfield LE: One test to rule them all: A qualitative study of formal, informal, and hidden curricula as drivers of USMLE “exam mania.” PloS One. 2023, 18:e0279911. 10.1371/journal.pone.0279911 Baniadam K, Elkadi S, Towfighi P, Aminpour N, Sutariya R, Chen HC. The impact on medical student stress in relation to a change in USMLE Step 1 examination score reporting to pass/fail. Med Sci Educ. 2023, 33:401–407. 10.1007/s40670-023-01749-4 Tackett, S., Jeyaraju, M., Moore, J., Hudder, A., Yingling, S., Park, Y. S., & Grichanik, M. (2022). Student well-being during dedicated preparation for USMLE Step 1 and COMLEX Level 1 exams. BMC Medical Education, 22 (1), 16. https://doi.org/10.1186/s12909-021-03055-2 Harden, R. M. (2001). AMEE Guide No. 21: Curriculum mapping: A tool for transparent and authentic teaching and learning. Medical Teacher, 23 (2), 123–137. https://doi.org/10.1080/01421590120036547 Al-Eyd, G., Achike, F., Agarwal, M., Atamna, H., Atapattu, D. N., Castro, L., et al. (2018). Curriculum mapping as a tool to facilitate curriculum development: A new School of Medicine experience. BMC Medical Education, 18 (1), 185. https://doi.org/10.1186/s12909-018-1289-9 Prideaux, D. (2003). ABC of learning and teaching in medicine: Curriculum design. BMJ, 326 (7383), 268–270. https://doi.org/10.1136/bmj.326.7383.268 Uchiyama, K. P., & Radin, J. L. (2009). Curriculum mapping in higher education: A vehicle for collaboration. Innovative Higher Education, 33 (4), 271–280. https://doi.org/10.1007/s10755-008-9078-8 Association of American Medical Colleges. (n.d.). Curriculum keywords (standardized vocabulary for tagging curricular content). Retrieved September 5, 2025, from https://www.aamc.org/about-us/mission-areas/medical-education/curriculum-resources Dexter, J., Koshland, G., Waer, A., & Anderson, D. (2012). Mapping a curriculum database to the USMLE Step 1 content outline. Medical Teacher, 34 (10), e666–e675. https://doi.org/10.3109/0142159X.2012.687477 Yoder, L.M., Flanagan, M., Thompson, B., Stephens, M. (2024). Mapping student-generated learning objectives against USMLE core content. Journal of Regional Medical Campuses . 7(2). https://doi.org/10.24926/jrmc.v7i2.5703. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 19 Dec, 2025 Reviewers agreed at journal 05 Nov, 2025 Reviewers invited by journal 05 Nov, 2025 Editor invited by journal 20 Oct, 2025 Editor assigned by journal 17 Oct, 2025 Submission checks completed at journal 17 Oct, 2025 First submitted to journal 13 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7850561","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":545632844,"identity":"f544793d-d907-404d-a6f1-64f01d9b14cd","order_by":0,"name":"Robert M. 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10:39:20","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60448,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7850561/v1/e2a2f12b93851c19d160177f.html"},{"id":96076347,"identity":"51a9d6cf-264c-4b51-8ab6-d2881b0de504","added_by":"auto","created_at":"2025-11-17 10:39:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":962458,"visible":true,"origin":"","legend":"\u003cp\u003eA. An example of \u0026nbsp;2025 USMLE® Content Outline (STEP) with the Cardiovascular System (top) and Skin and Subcutaneous Tissue (bottom) shown. B. A screenshot of a machine-readable, granular, hierarchical coding library that was built from the 2025 USMLE® Content Outline focusing on the Cardiovascular System.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7850561/v1/a42f0732dd7485475b30d8b0.png"},{"id":96076229,"identity":"bfa3cda9-9231-4368-9902-a654ff0553c0","added_by":"auto","created_at":"2025-11-17 10:39:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":172191,"visible":true,"origin":"","legend":"\u003cp\u003e2025 USMLE® Content Outline (STEP)-coded session learning objectives for our preclerkship cardiovascular system organ block. STEP codes are in the right column and session learning objectives are in the center column.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7850561/v1/32333fe4c97a7c9f14a71584.png"},{"id":96076263,"identity":"5afadf43-0275-48a7-ad42-bcc3465062bf","added_by":"auto","created_at":"2025-11-17 10:39:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":151990,"visible":true,"origin":"","legend":"\u003cp\u003eOperationalization of STEP codes. Two examples of a coded Cardiovascular Course Exam on ExamSoft.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7850561/v1/38c5d63f05fd0076b2fc7ca7.png"},{"id":96246519,"identity":"4b6748f1-b597-4526-93b4-57322b8abe1d","added_by":"auto","created_at":"2025-11-19 07:26:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1508572,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7850561/v1/315b118c-59e2-4af4-8c4a-f01a65558548.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Parallel to Aligned: A United States Medical Licensing Examination (USMLE®) Mapping and Assessment-Tagging Framework for Medical Education","fulltext":[{"header":"Background","content":"\u003cp\u003eIn many medical schools, students perceive that two curricula exist in \u0026ldquo;parallel\u0026rdquo; being the institutional curriculum that is formally taught and assessed, and the 2025 USMLE\u0026reg; Content Outline (STEP) that students must master independently and is self-directed (Burk-Rafel, J., et al. 2017, Geraghty, J.R. et al. 2023).This perception may increase student apprehension in choosing their study planning. For example, they may be required to study a large amount of mandatory content for their courses that is unrelated to STEP, and the additional workload may have a negative impact on performance and their overall wellbeing (Baniadam, K. et al., 2023, Burk-Rafel, J., et al. 2017, Geraghty, J.R. et al., 2023, Tackett et al., 2022). This perceived duality highlights the value of linking STEP directly to the institutional curriculum, especially to learning objectives and assessments. Doing so offers faculty and students a benchmark to understand where STEP topics are addressed and to realign their course instructional design to bridge coverage and sequence gaps and reduce redundancy. Providing these linkages through visualization, such as in dashboards, allows stakeholders to evaluate alignment and make intentional choices to strengthen connections between institutional objectives, STEP, and assessments (Harden, 2001, Al-Eyd, 2018).\u003c/p\u003e\u003cp\u003eCurriculum mapping plays a major role in curriculum development and planning and, overall, in the quality improvement process by forming relational linkages among institutional program objectives, course-level learning objectives, session-level learning objectives while allowing alignment with frameworks such as the AAMC Keywords and STEP (Harden, 2001; Al-Eyd et al., 2018, Prideaux, and Ugidama). These relational linkages can be visualized to the institutional stakeholders that may increase positive perceptions in alignment and intentionality. This alignment is facilitated by \u0026ldquo;tagging\u0026rdquo; curricular content, such as assessments, to STEP and AAMC Keywords, that allows for aggregated data summation, curation, and visualization.\u003c/p\u003e\u003cp\u003eAlthough not directly intended to reduce the perception of a \"parallel\u0026rdquo; curriculum and lacking an intentional coding system, approaches to map STEP to curricular elements exist. Dexter et al. (2012) developed an approach that deconstructed the STEP outline into Medical Subject Headings (MeSH) terms for use in their database, while Yoder et al. (2024) demonstrated how student-generated learning objectives could be mapped against STEP. In these studies, STEP is not formally coded or presented at a granular level that limits the standardization, depth, and utility in categorizing institutional STEP content and setting STEP benchmarks for curricular content development. STEP is granular at multiple levels that can create complexity, especially in MeSH term searching. Currently, coded AAMC Keywords offer a solution to standardizing curriculum content through tagging, however, these Keywords offer broad and simple medical and basic science terms that are not granular and require additional searching to find medical content definitions and are not directly connected to STEP. Currently, due to a perceived parallel curriculum, solutions in searching, collection, and visualization of standardized, granular STEP data content and related relational linkages are needed by medical school curriculum stakeholders to make effective decisions in planning a STEP-aligned curricular design. With an effective curricular map that is aligned to STEP, faculty and students can easily understand how the institution\u0026rsquo;s curriculum aligns with STEP and that mitigates negative student perceptions about an institution\u0026rsquo;s perceived ignorance of Step 1. Here, we describe how these codes are operationalized and show their role in bridging institutional learning objectives with STEP to align in-house curricular design to STEP, thus reducing the perception of a \u0026ldquo;parallel\u0026rdquo; curriculum. We created a machine-readable, granular, hierarchical coding library that was built from STEP. We have used these STEP codes to tag or link preclerkship session learning objectives and exam questions. To the best of our understanding, there exists no similar methods.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eUSMLE\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e® Content Outline\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs our reference, we used the 2025 USMLE Content Outline: https://www.usmle.org/sites/default/files/2022-01/USMLE_Content_Outline_0.pdf\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCode Library \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe created a hierarchical coding library by a top-down, left-to-right method in transferring data from the USMLE Content Outline to an Office 365 Microsoft Excel spreadsheet. The major Content Topic was the parent and from each bullet point downward, we assigned “2.1” as the first code. If there was another bullet point that had more than one description, then we created “2.1.1” etc. For “normal” processes, we created our in-house code as “1.0.” This was machine-readable and granular.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCurriculum Linking to Session Learning Objectives\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used ChatGPT 5 to generate matches between session learning objectives in preclerkship curriculum with the prompt: “I am a curriculum analyst at a medical school. I need to map USLME Step Codes to Session Learning Objectives. I need all the codes that are linked to that session learning objective in column c of the CV worksheet (CV Step practice). The master code library (USMLE Codes Library).”\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExam Tagging \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the ExamSoft Enterprise Portal (www.examsoft.com), in “Category Management” in the “ADMIN” drop-down menu, we created a “MED - 2024 USMLE STEP Codes” category. We created 18 categories for each STEP Content title. These categories were then available upon editing an exam question.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA hierarchical, machine-readable STEP coding library was developed from the 2025 integrated USMLE\u0026reg; Content Outline. Each code retained its parent\u0026ndash;child relationship within the outline that enabled alignment at both broad and granular levels. This coding library had 18 USMLE\u0026reg; Content Outline Content topics (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1. USMLE\u0026reg; Content Outline Content topics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;2025 USMLE\u0026reg; Content Outline Content topics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eHuman Development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eGastrointestinal System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eImmune System\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eRenal and Urinary System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eBlood and Lymphoreticular System\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePregnancy, Childbirth, and the Puerperium\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eBehavioral Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eFemale and Transgender Reproductive System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eNervous System and Special Senses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eMale and Transgender Reproductive System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSkin and Subcutaneous Tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eEndocrine System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eMusculoskeletal System\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eMultisystem Processes and Disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eCardiovascular System\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eBiostatistics, Epidemiology/Population Health, and Interpretation of the Medical Literature\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eRespiratory System\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eSocial Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFrom these Content Topics, a hierarchical structure was built with the major STEP topic as the parent. We used Microsoft Excel in a 2-column format to provide a machine-readable form. Reaching granular levels, based on the USMLE Content Outline, \u003cstrong\u003eFigure 1\u003c/strong\u003e shows an example of the 2025 USMLE\u0026reg; Content with the Cardiovascular System Content Outline (1 A) and our coded library (1 B). From top down, codes were created in-house that went from \u003cstrong\u003e2.1\u003c/strong\u003e Infectious and immunologic, including microbiologic and host response to insult to \u003cstrong\u003e2.1.1\u0026nbsp;\u003c/strong\u003eInfectious disorders: bacterial endocarditis, myocarditis based on the tabulated structure in the Content Outline. To account for normal conditions, for instance, in \u0026ldquo;normal\u0026rdquo; anatomy content, we created a \u003cstrong\u003e1.0\u003c/strong\u003e code that was linked to normal processes and, in this case, \u0026ldquo;\u003cstrong\u003eCS 1.0\u003c/strong\u003e Cardiovascular System: Normal Processes.\u0026rdquo; To demonstrate granularity, the coding for \u0026ldquo;Skin \u0026amp; Subcutaneous Tissue\u0026rdquo; is shown (1 B). From highest to lowest, \u003cstrong\u003eST 2.1\u003c/strong\u003e Infectious, immunologic, and inflammatory disorders, including microbiologic and host response to insult \u0026gt; \u003cstrong\u003eST 2.1.1\u003c/strong\u003e Infectious disorders and infestations \u0026gt; \u003cstrong\u003eST 2.1.1.1\u003c/strong\u003e Bacterial: cellulitis, erysipelas, impetigo, staphylococcal scalded skin syndrome; abscess, cutaneous, including septic abscess; anthrax (Bacillus anthracis); carbuncle; folliculitis; pilonidal cyst, infected; MSSA and MRSA skin infections; mycobacterial infections (e.g., leprosy, draining sinus); scarlet fever (group A Streptococcus).\u003c/p\u003e\n\u003cp\u003eUsing these codes, we have used the ChatGPT 5 generative AI tool to map them to our session learning objectives at multiple hierarchical levels. After the automated coding, we reviewed the linkages for accuracy. \u003cstrong\u003eFigure 2\u003c/strong\u003e shows an example of STEP-coded Session Learning Objectives for the Cardiovascular System Organ Block in our preclerkship curriculum.\u003c/p\u003e\n\u003cp\u003eTo tag our in-house preclerkship exams, in ExamSoft, we added a STEP catagory that contained our STEP codes. \u003cstrong\u003eFigure 3\u003c/strong\u003e shows an example of the operationalization of the STEP codes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHere, to the best of our knowledge, we show the operationalization of STEP through a machine-readable, hierarchical coding library. We show how these codes can be mapped to session-level learning objectives and to exam questions.\u003c/p\u003e\n\u003cp\u003eThis innovation’s utility comes through data collection and visualization. A challenge that we have at our medical institution is that students perceive that our curriculum is “disjointed,” and this reduces confidence that they will be prepared for their Step 1 exam. Students use third-party resources for studying and may not attend lectures and may not reach their potential on in-house exams leading to dissatisfaction. To provide a solution, we collect session-level learning objectives from our courses each academic year and have linked STEP codes to these. We are also mapping these STEP codes to our in-house exams. We have started to do semantic mapping with these codes and session-level learning objectives to visualize the coverage of STEP in our curriculum. For transparency and intentionality, we intend to share these dashboards with faculty and students.\u003c/p\u003e\n\u003cp\u003eAccording to the USMLE Step 1 Content Outline and Specifications, musculoskeletal, skin, and subcutaneous tissue account for approximately 8–12% of total questions, and the gastrointestinal system accounts for 6–10% (United States Medical Licensing Examination [USMLE], n.d.). It is possible to create dashboards of respectively covered content from the USMLE “tags” that we have mapped to our session-level learning objectives and to assessment questions that support our exam blueprinting initiatives. Although we are in the process of creating semantic mapping visualizations and dashboards for these benchmarks, we can now communicate with curriculum stakeholders that we are effectively mapping our preclerkship curriculum to USMLE content. In addition, the machine-readability of the code data allows generative artificial intelligence platforms to align both relational and curricular inventory, with the possibility to create custom dashboards for the curriculum as a whole or cross-sectionally at each course. Furthermore, curricular relationships are easily understood by faculty and students with this standardized USMLE coding. A limitation to prior studies is in the USMLE data structure and subsequent reporting. By coding and linking USMLE content to session-level learning objectives or exam questions directly, these relationships are explicit. Prior studies did not address direct linkages of session-level learning objectives to USMLE content (Dexter et al., 2012; Yoder, 2024).\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge, the high-granularity coding that this method provides is original and can be used to provide multi-institutional benchmarking and a common coding framework similar to the existing AAMC Keyword library. A limitation in the AAMC Keyword library is its lack in granularity that can lead to a lack of clarity to faculty and other stakeholders. However, the AAMC Keyword library can give information on the Step 1 discipline specifications (United States Medical Licensing Examination [USMLE], n.d.). For example, 45 to 55% of the Step 1 discipline covered is pathology (United States Medical Licensing Examination [USMLE], n.d.). This can be mapped to keyword K-064 pathophysiology and when mapped to session-level objectives and also to assessment questions, the coverage in the curriculum can be determined. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the present study focused on building the STEP coding library, the system is designed to be adaptable. Institutions can use this method by session-level mapping, in assessment tagging, in gap and redundancy analysis, in multi-institutional benchmarking, and integration with existing frameworks. In session-level mapping, faculty can assign STEP codes directly to course and session objectives, creating a relational map between institutional objectives and STEP content. For example, a session on allergic asthma could be coded to both RS (Respiratory System: asthma, obstructive airway disease) and IS (Immune System: hypersensitivity reactions). With assessment tagging, exam questions can be linked to STEP codes, allowing institutions to generate item banks that align both with their curriculum and USMLE emphasis. This enables performance dashboards that display how students perform on specific STEP domains. In gap and redundancy analysis, institutions can compare which domains are overrepresented (e.g., Cardiovascular, Gastrointestinal) and which are underrepresented (e.g., Social Sciences, Patient Safety). This provides an evidence-based approach to refining curricular balance and constructive alignment. With multi-institutional benchmarking, because the code library is standardized and machine-readable, two or more schools could compare their mappings to the same STEP domains. This creates opportunities for shared benchmarking, collaborative research, and shared curricular innovation across institutions. In integration with existing frameworks, the STEP code library can be layered alongside the AAMC Keyword Library or institutional program objectives creating a unified database that supports our efforts in aligning our curriculum to STEP and shortening the gap in the “parallel curriculum.”\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, a granular, machine‑readable STEP code library operationalizes the 2025 USMLE Content Outline for curriculum mapping and assessment. The approach is generalizable across courses and institutions and lays the groundwork for multi‑institutional benchmarking, improved transparency for learners and faculty, and scalable analytics and visualizations that connect objectives and assessments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSTEP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e2025 USMLE\u0026reg; Content Outline\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUSMLE\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States Medical Licensing Examination\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAAMC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAssociation of American Medical Colleges\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMeSH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedical Subject Headings\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCV\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCardiovascular\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArtificial Intelligence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to thank Dr. Kristy Motte, Ed.D. for her recommendations on improving this article and the Office of Academic Affairs team for resource support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR.M.B wrote the manuscript with figures and tables, used the AI-Assistant, and did the exam tagging. T.M. created the coding library. J.L. and V.V. consulted and reviewed the manuscript. D.D. provided the resources to do this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited States Medical Licensing Examination. USMLE\u0026reg; content outline. Federation of State Medical Boards \u0026amp; National Board of Medical Examiners. (2025). https://www.usmle.org/exam-resources/step-1-materials/step-1-content-outline-and-specifications\u003c/li\u003e\n\u003cli\u003eBurk-Rafel J, Santen SA, Purkiss J: Study behaviors and USMLE Step 1 performance: Implications of a student self-directed parallel curriculum. Acad Med\u003cem\u003e. \u003c/em\u003e2017, 92:S67\u0026ndash;S74. 10.1097/ACM.0000000000001916\u003c/li\u003e\n\u003cli\u003eGeraghty JR., Russel SM, Renaldy H, Thompson TM, Hirshfield LE: One test to rule them all: A qualitative study of formal, informal, and hidden curricula as drivers of USMLE \u0026ldquo;exam mania.\u0026rdquo; PloS One.\u003cem\u003e \u003c/em\u003e2023, 18:e0279911. 10.1371/journal.pone.0279911\u003c/li\u003e\n\u003cli\u003eBaniadam K, Elkadi S, Towfighi P, Aminpour N, Sutariya R, Chen HC. The impact on medical student stress in relation to a change in USMLE Step 1 examination score reporting to pass/fail. Med Sci Educ.\u003cem\u003e \u003c/em\u003e2023, 33:401\u0026ndash;407. 10.1007/s40670-023-01749-4\u003c/li\u003e\n\u003cli\u003eTackett, S., Jeyaraju, M., Moore, J., Hudder, A., Yingling, S., Park, Y. S., \u0026amp; Grichanik, M. (2022). Student well-being during dedicated preparation for USMLE Step 1 and COMLEX Level 1 exams. \u003cem\u003eBMC Medical Education, 22\u003c/em\u003e(1), 16. https://doi.org/10.1186/s12909-021-03055-2\u003c/li\u003e\n\u003cli\u003eHarden, R. M. (2001). AMEE Guide No. 21: Curriculum mapping: A tool for transparent and authentic teaching and learning. \u003cem\u003eMedical Teacher, 23\u003c/em\u003e(2), 123\u0026ndash;137. https://doi.org/10.1080/01421590120036547\u003c/li\u003e\n\u003cli\u003eAl-Eyd, G., Achike, F., Agarwal, M., Atamna, H., Atapattu, D. N., Castro, L., et al. (2018). Curriculum mapping as a tool to facilitate curriculum development: A new School of Medicine experience. \u003cem\u003eBMC Medical Education, 18\u003c/em\u003e(1), 185. https://doi.org/10.1186/s12909-018-1289-9\u003c/li\u003e\n\u003cli\u003ePrideaux, D. (2003). ABC of learning and teaching in medicine: Curriculum design. \u003cem\u003eBMJ, 326\u003c/em\u003e(7383), 268\u0026ndash;270. https://doi.org/10.1136/bmj.326.7383.268\u003c/li\u003e\n\u003cli\u003eUchiyama, K. P., \u0026amp; Radin, J. L. (2009). Curriculum mapping in higher education: A vehicle for collaboration. \u003cem\u003eInnovative Higher Education, 33\u003c/em\u003e(4), 271\u0026ndash;280. https://doi.org/10.1007/s10755-008-9078-8\u003c/li\u003e\n\u003cli\u003eAssociation of American Medical Colleges. (n.d.). Curriculum keywords (standardized vocabulary for tagging curricular content). Retrieved September 5, 2025, from https://www.aamc.org/about-us/mission-areas/medical-education/curriculum-resources\u003c/li\u003e\n\u003cli\u003eDexter, J., Koshland, G., Waer, A., \u0026amp; Anderson, D. (2012). Mapping a curriculum database to the USMLE Step 1 content outline. \u003cem\u003eMedical Teacher, 34\u003c/em\u003e(10), e666\u0026ndash;e675. https://doi.org/10.3109/0142159X.2012.687477\u003c/li\u003e\n\u003cli\u003eYoder, L.M., Flanagan, M., Thompson, B., Stephens, M. (2024). Mapping student-generated learning objectives against USMLE core content. \u003cem\u003eJournal of Regional Medical Campuses\u003c/em\u003e. 7(2). https://doi.org/10.24926/jrmc.v7i2.5703. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"assessment tagging, curriculum mapping, learning objectives, exam blueprinting, ontology codebook, undergraduate medical education, united states medical licensing examination","lastPublishedDoi":"10.21203/rs.3.rs-7850561/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7850561/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMedical students often experience a \u0026ldquo;parallel curriculum,\u0026rdquo; which is perceived or a real misalignment between what is taught in the formal institutional curriculum and, for licensing, the United States Medical Licensing Examination (USMLE\u0026reg;) content that they must master independently. By delivering transparency to the faculty and students, curriculum mapping institutional curriculum objectives and assessments to USMLE\u0026reg; content can reduce this perception by showing the scope and sequence of board-relevant topics through dashboards and the connected assessments.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo align USMLE\u0026reg; content to our curriculum, we developed and operationalized a granular, machine‑readable coding library derived from the 2025 USMLE\u0026reg; Content Outline (STEP) and to demonstrate its utility for session‑level mapping and assessment tagging.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eUsing a top‑down, left‑to‑right parse of the STEP, we constructed a hierarchical code library with the parent\u0026ndash;child relationships preserved. \u0026ldquo;Normal processes\u0026rdquo; were assigned 1.0 codes within each system to distinguish physiology/anatomy from pathology. We then used a structured prompt with a generative AI assistant to propose STEP codes for preclerkship session-level learning objectives. The library spans 18 STEP domains and supports alignment at multiple levels of granularity. Early use cases include (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) session‑level mapping to surface gaps and redundancies and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) assessment tagging to enable exam blueprinting by STEP domain.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo mitigate the \u0026ldquo;parallel curriculum,\u0026rdquo; these linked STEP codes can, in the future, be visualized at a course- or phase-level to provide faculty and students linkages between session-level course objectives and assessments to STEP. This coding library is generalizable across courses, phases, and external institutions and can be mapped by AI technologies.\u003c/p\u003e","manuscriptTitle":"From Parallel to Aligned: A United States Medical Licensing Examination (USMLE®) Mapping and Assessment-Tagging Framework for Medical Education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-17 10:38:34","doi":"10.21203/rs.3.rs-7850561/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-19T07:15:04+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"167734809715523151016096143222602237651","date":"2025-11-05T21:22:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-05T20:51:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-20T18:38:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-17T12:55:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-17T12:54:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-10-13T15:16:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7c923a86-2c94-4941-819d-f4c2fae857e1","owner":[],"postedDate":"November 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T19:23:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-17 10:38:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7850561","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7850561","identity":"rs-7850561","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}