Core Revision
The MSRA Professional Dilemmas paper: format, scoring and how to approach it
The Professional Dilemmas paper is 95 minutes, 50 questions, and half of your MSRA score. It contains no clinical knowledge at all: every question is a workplace scenario, pitched at a Foundation Year 2 doctor, and asks you either to rank the possible responses or to pick the three most appropriate from eight. It is the paper most candidates prepare least for and the one where structured practice moves scores the most. Here is how it is built, how it is marked, and how to approach it — checked against the NHS England MSRA pages and the official practice paper on 21 September 2026.
The format
| Question type | What you do |
|---|---|
| Ranking | Put four or five responses in order from most to least appropriate |
| Multiple choice | Choose the three most appropriate responses from eight |
Practise the ranking questions before the real thing.
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.
The official practice-paper instructions give a ranking question up to 20 marks. Fifty questions in 95 minutes is just under two minutes each. The scenarios are short but the options are not, and the time goes on reading five plausible responses and deciding between the two you cannot separate. There is no negative marking. There is an optional five-minute break after this paper before the Clinical Problem Solving paper begins.
How it is marked: near-miss scoring
This is the part that changes how you should answer. Ranking questions are not all-or-nothing. Each option you place is scored on how close it is to the position the expert panel gave it: exactly right earns full marks for that option, one place out earns most of them, and so on down. Getting the top and bottom responses right and muddling the middle still scores well. The consequence is that you should never leave a ranking incomplete and never spend three minutes agonising over positions two and three. The multiple-choice questions work similarly: each of your three choices that appears in the panel’s three earns marks, so two out of three is a good outcome, not a failure.
Your raw marks are scaled to a national mean of 250 and standard deviation of 40, the same as the clinical paper, and the two are added. MSRA results and ranking explains what the scaled score means for each specialty.
What it is testing
The paper is scored against three domains:
- Professional integrity — honesty, probity, taking responsibility, putting patients first when that costs you something;
- Coping with pressure — staying safe and effective under workload, conflict and uncertainty, and knowing when to escalate;
- Empathy and sensitivity — how you treat patients, relatives and colleagues, particularly the ones who are difficult.
The behaviours the paper rewards are the ones set out in the GMC’s Good Medical Practice. The panel who set the “correct” ranking are practising clinicians applying those standards, so the paper rewards the doctor who behaves as the GMC expects an F2 to behave: escalates appropriately, is honest with patients about errors, does not cover for an impaired colleague, does not abandon the ward to make a point, and deals with a problem now rather than at the end of the shift.
Five principles that resolve most rankings
- Patient safety first, always. If one option removes an immediate risk to a patient, it goes top, even if it is socially awkward.
- Deal with it yourself before escalating, unless it is beyond you. Speaking to the colleague directly usually ranks above going to the consultant; going to the consultant ranks above going to the GMC. Skipping steps ranks low; doing nothing ranks lowest.
- Honesty is not optional. Options that involve concealing an error, altering a record or misleading a patient sit at the bottom.
- Stay within your competence. Attempting something you are not trained for, to be helpful, ranks below asking for help.
- Do not punish, do not gossip. Confronting a colleague in front of patients, or discussing them with other juniors, is almost always the least appropriate response.
Most questions are settled by the first two. The difficulty is usually between two “reasonable” middle options, and near-miss scoring means that difficulty costs you very little.
How to prepare
Read Good Medical Practice once, properly. Then practise with timed questions and, crucially, read the explanations for the rankings you got wrong — the reasoning is the syllabus. The official practice paper (22 Professional Dilemmas questions and 48 clinical items, published as a PDF on the NHS England recruitment pages) is the best free calibration of the style; do it early rather than saving it. Then build volume: try the Professional Dilemmas trainer, and the MSRA Pack has 500 scenarios with explanations.
If you trained outside the NHS, the ranking conventions can feel arbitrary until you see the pattern; the Professional Dilemmas paper when you did not train in the NHS is written specifically for that.
Our tip: practise the timing, not just the reasoning
Candidates lose more marks to unanswered questions than to wrong rankings. In your last two weeks, do full 50-question sets in 95 minutes, and if you are not finishing, set a rule: 90 seconds, then commit and move on. A completed paper with a few near-misses beats a perfect first forty and ten blanks.
Quick answers
How long is the Professional Dilemmas paper?
95 minutes for 50 questions, followed by an optional five-minute break before the 75-minute Clinical Problem Solving paper.
What types of question are there?
Ranking questions (order four or five responses) and multiple-choice questions (choose three of eight).
Is there negative marking?
No. Ranking questions are scored on how close each placement is to the panel’s answer, so partial credit is the norm.
What is the paper based on?
Workplace scenarios at Foundation Year 2 level, scored across three domains — professional integrity, coping with pressure, and empathy and sensitivity — against the standards in the GMC’s Good Medical Practice.
How much of the MSRA is Professional Dilemmas?
Half. Each paper is scaled to a mean of 250 and the two are added.
Where is the official practice paper?
On the NHS England specialty recruitment MSRA pages, as a PDF with 22 Professional Dilemmas and 48 Clinical Problem Solving questions.
