Interview Preparation

How to stop guessing on the MSRA Professional Dilemmas paper

October 11, 2026 by PHJ Staff

The Professional Dilemmas paper is worth as much as the Clinical Problem Solving paper, and almost nobody revises for it properly. That's not a criticism. CPS looks like every exam you've sat since second year, so you know how to prepare for it. PD looks like a personality test, so people either assume it can't be revised or do a few questions the night before and hope.

It can be revised. The paper has a mark scheme, the mark scheme rewards a specific skill, and that skill improves quickly with the right kind of practice. This post explains what the paper is, how it's marked, why candidates lose marks in a predictable place, and how to spend four weeks on it without wasting them.

What the PD paper actually is

The MSRA is the Multi-Specialty Recruitment Assessment, the computer-based exam sat by applicants to GP training and a growing list of other specialties. It has two papers. Clinical Problem Solving tests medicine. Professional Dilemmas is a situational judgement test: you're given a scenario, told you're the F2 doctor in it, and asked what the most appropriate responses would be. Not the kindest, not the safest-sounding, the most appropriate according to the GMC's standards for doctors.

Every scenario is written from the F2 perspective regardless of your actual grade. If you're an ST3 applying to GP you still answer as an F2, with an F2's competence, supervision and escalation routes. Candidates who forget this tend to rank "handle it yourself" options too highly.

The paper is 50 scenarios in 95 minutes. Eight of the 50 are pilot items that don't count towards your score, and you can't tell which. There are two question types, in two parts. Ranking questions give you four or five actions and ask you to order them from most to least appropriate. Multiple-choice questions give you eight actions and ask you to pick the three that together best resolve the situation. The split is roughly half and half.

Three domains are assessed: professional integrity, coping with pressure, and empathy and sensitivity. Each scenario is tagged to one of them, though the better scenarios lean on more than one.

How it's marked, which is the bit most people get wrong

Ranking questions aren't marked right or wrong. They're marked on closeness. Each of the five options earns full marks if you put it in its correct position and progressively fewer the further away it lands. A ranking question is worth 20 marks, up to 4 per option, and NHS England's own blueprint describes the marking as a near-miss approach: a wrong answer can score more than a missed one. What the blueprint doesn't publish is the exact marks-by-distance table, so the 4, 3, 2, 1, 0 scale you'll see on most prep sites is an inference, not an official figure. The principle holds either way: a near miss costs you a mark or two, not the whole question.

Multiple-choice questions are simpler: 4 marks for each of your three selections that matches the examiners' three, 12 marks available, no penalty for a wrong pick.

The practical consequence is large. Suppose the correct order is A, B, C, D, E and you answer A, C, B, D, E. You've swapped two adjacent options in the middle. Under closeness scoring you keep 18 of 20. Now suppose you answer A, B, C, E, D. Same thing, different pair, still 18. But answer E, B, C, D, A, getting the extremes backwards, and you've lost 8 marks on one question.

So the scoring tells you two things. Getting the best and worst options right matters disproportionately, and you can afford to be slightly unsure about the middle. Most candidates have that backwards. They agonise over whether "speak to the registrar" goes second or third and then put a plausible-sounding but wrong option at the top.

Where the marks actually leak

The big losses come from getting an extreme wrong, but those are rare once you've done a few dozen questions. The worst option is usually the one where you lie, ignore something, or hand a problem to someone with no business having it. You'll spot it. The best option is harder but still learnable, because it's nearly always the one that deals with the immediate issue, stays honest, and keeps the patient at the centre.

The routine losses, the ones that add up across a whole paper, come from positions two, three and four. Two marks here, two marks there, forty times over.

Take a typical scenario. You're the F2 on a surgical ward. A nurse tells you a patient was given a dose of a drug this morning that wasn't prescribed; the patient is well and the drug is low risk. The options include: assess the patient and document; tell the patient what happened and apologise; inform your registrar; complete an incident report; and ask the nurse to let you know if anything similar happens again.

Most candidates put the last one last, correctly, and put the clinical assessment first, also correctly. Then they stall. Is telling the patient more important than telling the registrar? Does the incident report come before or after the apology? Those aren't questions of instinct. The GMC answers them in Good Medical Practice: paragraph 45 makes being open with the patient a duty, not an optional courtesy, and the same section expects you to report the incident through the proper system. Candour to the patient sits above the paperwork. If you can name the paragraph, you stop guessing.

That's the skill the paper rewards. Not knowing right from wrong, which everyone does, but being able to say which of two reasonable actions the GMC would put first, and why.

The three domains, in plain terms

Professional integrity is the honesty paper. Confidentiality, candour, gifts, accurate records, raising concerns about a colleague, not lying to make a problem go away. The options that lose here are the ones that sound efficient and involve a small deception.

Coping with pressure is the prioritisation paper. Two bleeps at once, a registrar who won't answer, a consultant asking you to do something outside your competence, a shift you can't stay for. The options that lose here either abandon a patient or pretend you have capacity you don't.

Empathy and sensitivity is the communication paper. Breaking bad news, angry relatives, a patient who won't take advice, a colleague in tears. The options that lose here are the ones that solve your problem rather than the patient's.

You'll find you're naturally stronger in one of the three. That's useful information, because the weak domain is where the cheap marks are.

How to spend four weeks on it

Week one: read Good Medical Practice 2024. The whole thing. It's shorter than you think and it is, quite literally, the mark scheme. Pay particular attention to the paragraphs on confidentiality (22), candour (45), records (69), raising concerns (75) and gifts (96), because the paper returns to them constantly. If your notes are from before 2024 the paragraph numbers have changed.

Week two: sit the official practice paper from NHS England under timed conditions, then go through the answer key and write down, for every option you placed wrongly, which GMC principle decided it. Don't just note that you were wrong. Note why.

Week three: volume. Ranking questions, under time, in the exam ratio. You're building the reflex of spotting the worst option in five seconds and the best in fifteen, so you can spend the remaining time on the middle. Review every question, including the ones you scored full marks on, because a right answer for the wrong reason won't survive a different scenario.

Week four: work your weak domain and your weak principles. If your reviewing has been honest you'll know what they are. Stop doing random questions and do targeted ones. Sit one more timed mock at the end of the week.

And a note on resources. The big clinical question banks all have a PD section, usually a couple of hundred questions marked right or wrong with a paragraph of explanation. They're fine for volume. What they don't do is mark the way the exam marks or tell you which principle you keep getting wrong, and that second thing is where the improvement is.

Where MSRA Practice comes in

We built MSRA Practice to do the two things the general banks don't. It marks ranking questions on closeness, the way the exam does, so after every question you see your order against the correct one and exactly where the marks went. And every option in every scenario is explained against Good Medical Practice 2024 with the paragraph number, so the app can tell you, after twenty or thirty questions, that you're losing most of your marks on candour scenarios and almost none on confidentiality. Then you practise candour until you're not.

It's 150 scenarios, split evenly across the three domains, 110 ranking and 40 choose-three, all framed from the F2 perspective. It covers the PD paper only. There's no clinical content, no subscription and no app to install.

The first ten questions are free, with full rationales, and you don't need an account to try them. If they're useful, the rest costs £29.99 for access until the end of the next sitting. If they're not, you've lost twenty minutes and learned something about where you stand.

Start the 10 free questions

Frequently asked questions

What does MSRA stand for? Multi-Specialty Recruitment Assessment. It's a computer-based exam, sat at Pearson VUE centres, used to shortlist and rank applicants for GP and a number of other specialty training programmes in the UK. It's made up of two papers: Clinical Problem Solving and Professional Dilemmas.

How much of the MSRA is the Professional Dilemmas paper? Half, for most specialties. Each paper is scored on its own normalised scale (for GP, a mean of 250 and standard deviation of 40) and the two are combined, so a weak PD performance costs you as much as a weak CPS one. A few specialties weight the papers differently, so check your own specialty's applicant guide.

Is the MSRA PD paper negatively marked? No. There's no penalty for a wrong selection in a multiple-choice question, and ranking questions award partial marks for near misses. Always answer everything.

Can you revise for the Professional Dilemmas paper? Yes. It's a test of how well you know and can apply the GMC's standards for doctors, and those are written down. Reading Good Medical Practice 2024 and practising ranking questions under time both move your score.

Which specialties use the MSRA? NHS England's current list is General Practice ST1, Core Psychiatry CT1, Core Surgical Training CT1, Clinical Radiology ST1, Obstetrics and Gynaecology ST1, ACCS Emergency Medicine CT/ST1, Nuclear Medicine ST3, Anaesthetics CT1, Community Sexual and Reproductive Health ST1, Neurosurgery ST1 to ST3 and Ophthalmology ST1, plus Broad Based Training and Trauma and Orthopaedics in Scotland. Paediatrics no longer uses it. For GP and Core Psychiatry there is no interview: your MSRA score is the whole selection process, and for Core Psychiatry a tied score is broken on the Professional Dilemmas paper first. For 2027 recruitment, which opens on 22 October 2026, there are two sittings: January 2027 for all specialties and February 2027 reserved for GP and Core Psychiatry applicants.

Does the exam use Good Medical Practice 2024 or the older version? The 2024 edition, which came into effect on 30 January 2024. If you're using revision notes written before then, the paragraph numbering has changed.

Sources

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