MIR exam: how the test assesses clinical reasoning
Table of contents
A 34-year-old woman arrives at the emergency department with fever and pain on urination for two days. Her blood pressure is stable, there is no flank pain and the pregnancy test is negative. The vignette provides the urine sediment and asks for the most appropriate next step. The candidate has four options and four and a half hours to solve, along with 199 other similar questions, the Examen MIR. There is no patient in the room. The reasoning must fit into a mark on the answer sheet.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
This scene sums up what the Spanish exam demands: a clinical decision in a vignette, under time pressure and with a scoring system that penalizes a guess. This text explains what the Examen MIR is, how the call organizes the exercise and the scoring scale, what is covered, how the score is built, what the studies say and how to train. At the end there is a table, frequently asked questions and a checklist.
Key points
- The MIR is the annual exam for access to specialized health training in Medicine in Spain, called by the Ministerio de Sanidad and published in the BOE (Orden SND/854/2026).
- The Medicine exercise has 200 questions plus 10 reserve questions, each with four options and one correct answer, in four and a half hours (Orden SND/854/2026).
- Each correct answer is worth three points, each wrong answer subtracts one point and blank questions neither add nor subtract; the exercise score is normalized against the best group of results (Orden SND/854/2026).
- The total score adds the exercise score (up to ninety points on the normalized scale) and the academic merits score (up to ten points on the same logic) (Orden SND/854/2026).
What the Examen MIR is
MIR stands for Médico Interno Residente. In practice, the name designates the selective exam with which physicians holding a qualifying degree compete for places in specialized health training in Medicine in the Spanish system. The annual call approves the offer of places and the exam rules; the 2026 call, for the start of training in 2027, is in Orden SND/854/2026, published in the Boletín Oficial del Estado.
The broader legal basis is in Ley 44/2003 and Real Decreto 589/2022. The Ministerio de Sanidad runs the process and publishes lists and resolutions on the Ministry page (press release).
In the 2026/2027 call, the Medicine offer is 9,676 places, of which 9,377 are publicly owned and 300 are at private centers, plus specific quotas described in the order itself (Orden SND/854/2026; Sanidad). The number changes every year; what does not change is the logic: the exam ranks candidates and the choice of place follows the total score.
Where the exam fits in Miller's pyramid
In 1990, George Miller described four levels of clinical assessment: knows, knows how, shows how and does (Miller, 1990). The Examen MIR is multiple choice with vignettes and, when well written, asks for the second level: applying knowledge to a case. It does not ask for an examination in front of an examiner. For clinical formats, see the AMC Clinical Exam and the second stage of Revalida. For other written exams, USMLE Step 2 CK, PLAB and UKMLA and MCCQE.
How the exam works
The selection process has two parts: the assessment of academic merits and the multiple-choice exercise. Both add up to the individual total score that ranks the choice of place (Orden SND/854/2026).
The exercise
For Medicine, the exercise consists of answering a questionnaire of 200 questions plus 10 reserve questions. Each question has four options and only one correct answer. The duration is four and a half hours (Orden SND/854/2026).
In the 2026/2027 call, the exercise is scheduled for January 23, 2027. The call begins at 14:00 (13:00 in the Comunidad Autónoma de Canarias), after identity verification from 13:00 (12:00 in the Canarias) (Orden SND/854/2026). The possible exam venues are listed in the order.
The examining commissions approve the question paper and the provisional list. There is a period for appeals; then the definitive list is published, and annulled questions may be replaced by reserve ones. The official papers are published later on the Ministry of Health page (Orden SND/854/2026).
Rules for the day
The order details the permitted materials: original official identity document, transparent blue or black pen and a small transparent water bottle without a label. Digital watches, mobile phones and other communication devices are prohibited; the only watch exception is an analogue wristwatch with hands, without digital functions (Orden SND/854/2026). Failure to comply may annul the exam.
Who may sit the exam
For Medicine places, a Spanish degree that qualifies for the profession is required, or recognition, homologation or equivalence of a foreign degree (Orden SND/854/2026). Candidates from countries whose official language is not Spanish need a minimum level of C1, except for exceptions (Orden SND/854/2026; RD 589/2022).
After the score: choosing a place
Anyone who scores above zero on the exam may take part in the choice and allocation of places, electronically or in person, according to the resolution that calls these proceedings (Orden SND/854/2026). There is an extraordinary call for vacant places and specific rules for the disability quota.
What the exam covers
Annex II of the call sets out the subject areas of the exam for each degree. For Medicine, the official reference is Orden ECI/332/2008, which sets the requirements for university degrees that qualify for the practice of Medicine (Orden SND/854/2026, annex II).
This order describes the minimum modules of the Medicine degree: morphology, structure and function; social medicine and communication; human clinical training; diagnostic and therapeutic procedures; and supervised practice (Orden ECI/332/2008). Clinical training covers pathologies by system, pediatrics, psychiatry, family medicine, emergencies, history taking and examination; procedures cover test indications, pharmacology and imaging.
In practice, the vignettes mix internal medicine, surgery, gynecology and obstetrics, pediatrics, psychiatry, emergencies and primary care. There is no question-by-question syllabus; the official map is that of Spanish medical training. Studying only lists of specialties without practicing decision-making in a case usually fails.
| Block (Orden ECI/332/2008) | What the rule emphasizes | How this usually appears in the vignette |
|---|---|---|
| Morphology, structure and function | Bases of the structure and function of the body | Interpretation of a pathophysiological finding |
| Human clinical training | Recognize, diagnose and guide the management of the main pathologies | Most likely diagnosis or short differential |
| Diagnostic and therapeutic procedures | Indication, risk and benefit of tests and treatments | Next step: test, drug or course of action |
| Social medicine and communication | Ethics, public health, evidence and communication | Priority, prevention or decision with the patient |
| Supervised practice | Clinical reasoning under supervision in the rotation | Emergency or primary care case |
How the scoring works
The call clearly separates the exam score from the academic merits score (Orden SND/854/2026).
Raw exam score
Each correct answer is worth three points; each wrong answer deducts one; blank questions are not scored (Orden SND/854/2026). A random guess tends to hurt; leaving a blank on an item with no reasonable hypothesis is usually safer than marking by force.
Exam normalization
The mean of the top ten percent of individual scores is calculated; ninety points correspond to this mean. A correction factor converts the individual score into the final exam score (Orden SND/854/2026). To choose a place, the exam score must be above zero; zero or negative means a mention of eliminated.
Academic scale
Merits use the average of the personal certification record. Without a valid certification, the average of 5.00 is applied automatically (Orden SND/854/2026). Among those who exceeded the minimum on the exercise, the average of the top ten percent of records corresponds to ten points, with an analogous correction factor.
Total score and ties
The individual total score adds the final exercise score (when above zero) and the academic merits score (Orden SND/854/2026). In a tie, the higher number of correct answers prevails, then the lower number of errors; if the tie persists, the alphabetical order of annex IV applies.
The exercise weighs far more than the scale in the normalized score, but the record matters at the margin between close rank numbers.
How clinical reasoning appears in the questions
A good MIR question rarely asks only for the name of a disease. It tells a short story and asks for the most likely diagnosis, the next step, the treatment or the finding that changes management. That is what Eva described about clinical reasoning: gathering information, generating hypotheses and testing them (Eva, 2005).
Read the task before the story
The first useful line is the task: diagnosis, test, drug, management. Anyone who starts with the labs and only then finds out what the question wants wastes time. Mark the task and return to the vignette with a filter.
Generate two or three hypotheses early
With age, sex, setting and complaint, you can already build a short differential. The following data strengthen, weaken or replace hypotheses. What is measured is the quality of the path, not only the final label (Ilgen et al., 2012).
Watch out for the plausible distractor
The four options usually include clinically possible alternatives. Classic mistake: treating the most serious imaginable disease when the vignette describes a stable picture, or ordering the most sophisticated test before stabilizing. If two options look good and you cannot tell them apart, sometimes it is better to leave it blank.
Time and pace
Two hundred questions in four and a half hours give a little more than a minute per item. Easy items give time back to the hard ones. A steady strategy is one pass with clear decisions, then only the marked items. The orden fixes the total duration, not an official pace (Orden SND/854/2026).
What studies say about multiple-choice exams
There is little international literature that assesses the Spanish MIR as a complete psychometric instrument, but there are works that use the exam itself as material and others that study what high-stakes written exams measure.
The MIR as an object of study
Madrid-García and colleagues used rheumatology questions from the Spanish exam for access to specialized training as study material (Madrid-García et al., 2023). Other works discuss the choice of Medicina Familiar y Comunitaria over two decades of MIR (Torres Moreno, 2025; 2024 analysis) and comment on specific editions of the exam (MIR 2020-2021).
What the written exam can measure
Miller placed multiple choice in the realm of knowing and knowing how (Miller, 1990). Eva showed that clinical reasoning can be taught and observed if the task is clear (Eva, 2005). A consensus statement on assessing diagnostic reasoning reinforced the need for instruments aligned with what is meant to be measured (Ilgen et al., 2012). In other high-stakes written exams, performance was associated with later measures in residency (Sharma et al., 2019; Morrison et al., 2014).
The practical reading is simple: the exam does not measure empathy at the bedside, but it measures the ability to apply knowledge to cases. Training only memorization leaves out what the question asks.
How to train reasoning for the MIR
Training for the MIR is training decision-making under a scoring rule, not just accumulating summaries. Official references: the current call, the answer keys and booklets from the Ministerio de Sanidad, and Orden ECI/332/2008 as a map of competencies.
Build an active bank, not a passive one
Solving official items matters more than rereading the same chapter. After each block, classify the error: knowledge, reading of the task, a guess or early closure. Without that, the same error comes back.
Simulate the time and the scoring rule
Do sessions of fifty or one hundred items with a clock and the official rule. Note how many you left blank on purpose. The goal is not to have zero blanks; it is to leave blank only what does not discriminate.
Train the next step
Many questions are about management. Force the sentence: the next step is… and only then the diagnosis. This reduces marking the name of the disease when the question asked for management.
Orden ECI/332/2008 describes clinical training and procedural competencies: recognize, diagnose, guide management and order tests with judgment. In the vignette, this appears as a choice between test, drug or expectant management. Reading the question up to the verb (diagnose, order, avoid) before the options prevents marking the disease label when the task was the next step.
Types of error to label after a block
Without labels, the official bank becomes volume without pattern correction. After each session with the rule of three points per correct answer and minus one per error (Orden SND/854/2026), classify like this:
- Incomplete reading: you ignored pregnancy, allergy, instability or the word "except".
- Early closure: you chose the familiar diagnosis and did not update it with the laboratory finding on the last line.
- Penalized guess: you marked by weak elimination on an item that should have been left blank.
- Management swapped for label: the question asked for the next step and the mark was the name of the disease.
- Poorly distributed time: you spent too long at the start and rushed the last dozens with more errors.
- Clinical Spanish: you wasted time mentally translating terms that the official booklets already use consistently.
Take care of your clinical Spanish
The exam is in Spanish. Anyone who studied in another language needs to read official vignettes until the terminology becomes automatic. The C1 for certain foreign candidates is in the call for applications; even if exempt, clinical vocabulary saves time (Orden SND/854/2026).
Compare formats, without mixing strategies
The MIR penalizes errors; other written exams may not use the same penalty. When training with banks from other countries, adjust your strategy to the Spanish rule. See also USMLE Step 2 CK, PLAB and UKMLA and MCCQE.
Four and a half hours for two hundred questions plus reserve demand a steady pace (Orden SND/854/2026). Fifty-item drills help with content; at least one long drill per week at the end of the cycle calibrates fatigue and the decision to leave items blank. The plantilla provisional and the appeal deadline exist after the exam: the useful training is marking with the same discipline you will use on the answer sheet, not discussing an informal answer key during the break.
Checklist for the final stretch
- I have read Orden SND/854/2026 (or the call for applications in force for my year) and noted the date, duration and scoring rule.
- I know the exam has 200 questions plus 10 reserve, with four options.
- I understand the normalization: exam up to ninety points and scale up to ten points on the scale described in the order.
- I know what happens if I do not submit valid academic certification (average 5.00 by default).
- I have a study map aligned with Orden ECI/332/2008, not just a list of specialties.
- I have trained with the official scoring rule and practiced leaving items blank on purpose.
- I have done at least one long mock exam with the official time.
- I have an error notebook classified by type of failure.
- I have reviewed the rules on devices and permitted materials on exam day.
- I have already looked at how the choice of plaza works after the score.
Want to train differential diagnosis every day, without losing your study rhythm? Play the case of the day on NEXO.
How NEXO helps train MIR reasoning
NEXO offers one clinical case per day, with fictional cases with a real clinical presentation, to be solved in up to six clues. Each clue adds a piece of data and you decide when you already have enough information for the diagnosis. It is a short differential diagnosis drill between one block of MIR questions and the next.
The format does not replace the official question bank or the four-and-a-half-hour mock exam, but it exercises pulling data together, keeping hypotheses open and not closing too early. See the NEXO Economy. Those coordinating a study group can get to know NEXO Closer. Researchers, reviewers and creators will find NEXO Researcher, NEXO Curator and NEXO Creators.
Frequently asked questions
What is the Examen MIR?
It is the annual selective exam for access to specialized health training positions in Medicine in Spain, called by the Ministerio de Sanidad and published in the BOE (Orden SND/854/2026).
How many questions does the Medicine paper have?
Two hundred questions plus ten reserve questions, each with four options and one correct answer, in four and a half hours (Orden SND/854/2026).
How is each question scored?
Three points for a correct answer, minus one point for a wrong answer; blank questions neither add nor subtract points (Orden SND/854/2026).
Does the academic score count for much?
On the scale of the call, the exam is normalized against ninety points and the academic score against ten points (Orden SND/854/2026). The academic record matters at the margin, but the exam weighs more.
What should I study?
Annex II refers, for Medicine, to Orden ECI/332/2008, which describes the competencies of the degree in Medicine. There is no question-by-question syllabus in the call.
Do I need C1 Spanish?
Nationals of states whose official language is not Spanish must prove a minimum C1 level, with the exceptions set out in the call and in RD 589/2022 (Orden SND/854/2026).
When is the exam for the 2026/2027 call?
The exam is scheduled for January 23, 2027 (Orden SND/854/2026; Sanidad). Future calls will have a new orden.
References
- Ministerio de Sanidad. Orden SND/854/2026, de 4 de agosto, oferta de plazas y convocatoria de pruebas selectivas 2026 para el acceso en 2027 a formación sanitaria especializada. BOE-A-2026-17429. [https://www.boe.es/buscar/doc.php?id=BOE-A-2026-17429](https://www.boe.es/buscar/doc.php?id=BOE-A-2026-17429)
- Ministerio de Sanidad. Nota de prensa sobre la convocatoria de formación sanitaria especializada 2026/2027. [https://www.sanidad.gob.es/gabinete/notasPrensa.do?metodo=detalle&id=6972](https://www.sanidad.gob.es/gabinete/notasPrensa.do?metodo=detalle&id=6972)
- Ministerio de Educación y Ciencia. Orden ECI/332/2008, de 13 de febrero, requisitos de los títulos que habilitan para la profesión de Médico. BOE-A-2008-2674. [https://www.boe.es/diario_boe/txt.php?id=BOE-A-2008-2674](https://www.boe.es/diario_boe/txt.php?id=BOE-A-2008-2674)
- Jefatura del Estado. Ley 44/2003, de 21 de noviembre, de ordenación de las profesiones sanitarias. [https://www.boe.es/buscar/act.php?id=BOE-A-2003-21340](https://www.boe.es/buscar/act.php?id=BOE-A-2003-21340)
- Ministerio de Sanidad. Real Decreto 589/2022, de 19 de julio, normas aplicables a las pruebas anuales de acceso a plazas de formación en especialidades en Ciencias de la Salud. BOE-A-2022-12205. [https://www.boe.es/buscar/doc.php?id=BOE-A-2022-12205](https://www.boe.es/buscar/doc.php?id=BOE-A-2022-12205)
- Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990. [https://pubmed.ncbi.nlm.nih.gov/2400509/](https://pubmed.ncbi.nlm.nih.gov/2400509/)
- Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2005. [https://pubmed.ncbi.nlm.nih.gov/15612906/](https://pubmed.ncbi.nlm.nih.gov/15612906/)
- Ilgen JS, Humbert AJ, Kuhn G, et al. Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. Acad Emerg Med. 2012. [https://pubmed.ncbi.nlm.nih.gov/23279251/](https://pubmed.ncbi.nlm.nih.gov/23279251/)
- Madrid-García A, et al. Assessment with ChatGPT and GPT-4 of the rheumatology questions of the Spanish exam for access to specialized medical training. Sci Rep. 2023. [https://pubmed.ncbi.nlm.nih.gov/38092821/](https://pubmed.ncbi.nlm.nih.gov/38092821/)
- Reflexiones sobre el examen MIR (2020-2021). Rev Esp Salud Publica. 2022. [https://pubmed.ncbi.nlm.nih.gov/35236819/](https://pubmed.ncbi.nlm.nih.gov/35236819/)
- Torres Moreno MP. Evolution quotation and demand of Family and Community Medicine in MIR 2002-2023. Semergen. 2025. [https://pubmed.ncbi.nlm.nih.gov/39657502/](https://pubmed.ncbi.nlm.nih.gov/39657502/)
- Choice of Family and Community Medicine in the MIR 2002-2023. Semergen. 2024. [https://pubmed.ncbi.nlm.nih.gov/38507828/](https://pubmed.ncbi.nlm.nih.gov/38507828/)
- Sharma A, et al. USMLE Step 2 CK: Best Predictor of Multimodal Performance in an Internal Medicine Residency. J Grad Med Educ. 2019. [https://pubmed.ncbi.nlm.nih.gov/31440335/](https://pubmed.ncbi.nlm.nih.gov/31440335/)
- Morrison CA, Ross LP, Fogle T, Butler A, Miller J, Dillon GF. Relationship between NBME clinical self-assessment performance and USMLE Step 2 CK. Teach Learn Med. 2014. [https://pubmed.ncbi.nlm.nih.gov/25318033/](https://pubmed.ncbi.nlm.nih.gov/25318033/)