Core Revision
The Professional Dilemmas paper when you didn’t train in the NHS
The Core Revision TeamWritten with the IMG Hub · 9 min read
Published 11 July 2026 · Checked against sources current July 2026
Half your MSRA score comes from a paper with no clinical knowledge in it at all. The Professional Dilemmas paper presents workplace scenarios — a colleague who smells of alcohol, a consultant who dismisses your concern, a mistake you notice at 5:55pm — and asks you to rank the possible responses. For doctors who grew up professionally inside the NHS, the “right” ranking often feels obvious. If you trained elsewhere, it often is not — and that difference is the single most fixable gap in an IMG’s MSRA preparation.
What the paper is really testing
PD scores you against three domains: professional integrity, empathy and sensitivity, and coping with pressure. But beneath the domains sits one source document: the GMC’s Good Medical Practice. Almost every scenario is a dramatised clause of it — patient safety first, honesty when things go wrong, respect for colleagues, knowing the limits of your competence, escalating early. Read it once, slowly, before you do anything else. It is short, and it is the answer key.
The assumptions that trip up doctors who trained abroad
Escalating early is strength, not weakness
In many health systems, asking a senior for help too readily reads as incompetence, and handling everything yourself reads as skill. The NHS assumption is the reverse: recognising your limits and escalating early is the professional behaviour, and quietly soldiering on past your competence is the dangerous one. When two options differ on this, the escalating option almost always ranks higher.
Hierarchy never outranks safety
Where training cultures are steeply hierarchical, challenging a consultant can feel unthinkable. PD scenarios are frequently engineered to test exactly this: the senior is wrong, and the top-ranked answer involves respectfully raising the concern — then escalating past them if needed. Deference that leaves a patient at risk ranks near the bottom, every time.
Sitting the MSRA? See where you stand.
Try twenty original MSRA questions, ten Professional Dilemmas and ten Clinical Problem Solving, marked on the near-miss principle NHS England describes. Free, no card and the first five are open to all.
Mistakes are told to the patient
The duty of candour — telling patients openly when something has gone wrong, apologising, and explaining what happens next — is legally and professionally embedded in the NHS in a way that surprises many IMGs. Options that involve honesty with the patient rank above options that quietly fix the problem, even when the quiet fix feels kinder or safer for your career.
The team includes everyone
Receptionists, pharmacists, practice managers and nurses appear in scenarios as colleagues whose concerns carry weight. Options that dismiss a non-doctor’s worry rank poorly. If your instinct sorts the workplace by rank, retrain it to sort by information: whoever noticed the problem matters.
Ranking questions: think in principles, not stories
Candidates who struggle try to imagine what they personally would do. Candidates who score well ask: which option best serves patient safety; which is most honest; which respects colleagues; which addresses the problem now rather than later? Rank by those tests in that rough order and the “ideal doctor” the paper imagines comes into focus. It is not asking about you; it is asking whether you can recognise the principles in action.
IMGs as a group score lower on situational judgement papers than UK graduates — the research literature (including work in the BJGP) is consistent about the gap and about its best explanation: familiarity with the cultural context, not capability. The gap narrows with exposure and structured practice. We wrote more about the evidence in our differential attainment piece — it is worth reading, because knowing the gap is closable changes how it feels to work on it.
How to prepare, concretely
- Read Good Medical Practice 2024 first. One sitting. Everything else builds on it.
- Practise little and often, from the start. PD judgement builds like language fluency — twenty minutes most days for two months beats a heroic final week. The MSRA Pack has Professional Dilemmas scenarios in both ranking and choose-three formats.
- Review why rankings are right, not just what they were. The reasoning transfers; memorised answers do not, because the scenarios never repeat exactly.
- If you are working in the NHS, treat the job as the textbook. Watch how good colleagues raise concerns, hand over, apologise, escalate. The paper is a simulation of the ward you are standing on.
- Learn the vocabulary of the culture — safety-netting, duty of candour, significant event, freedom to speak up. Our free NHS Jargon Decoder and Consultation Phrasebook exist for exactly this.
Doctors sometimes experience the PD paper as a judgement on their character, and a low practice score stings accordingly. It is not that. It is a fluency test in a professional dialect you have not spoken for long — and dialects are learned by immersion and practice, which is precisely what the weeks before your sitting are for.
Practise the judgement style, free
Our Professional Dilemmas Trainer teaches the ranking logic scenario by scenario, grounded in GMC Good Medical Practice — free, no sign-up.
Try the PD Trainer Explore the IMG Hub →Sources & the small print. GMC Good Medical Practice 2024; MSRA test specification (Professional Dilemmas paper); BJGP research on differential attainment in situational judgement assessments. General careers information, not immigration or legal advice — always check the current person specification, the GP National Recruitment Office and Oriel before acting. Written by the Core Revision team.
