MSRA Professional Dilemmas: how to reason through a ranking

Professional Dilemmas is 50 items in 95 minutes, sat as the second paper of the MSRA. Two response formats appear across it: ranking items, where you place five possible responses to a scenario in order from most to least appropriate, and select-the-three items, where you choose the three most appropriate actions from a list of eight.

Marking rewards how close your answer is to the reference answer, not an all-or-nothing match, and there is no negative marking. That makes every item worth attempting in full: a partially wrong ranking still earns partial credit, while a blank item earns none. The score reported is normalised across candidates, and NHS England is explicit that there is no stated maximum, so a raw sense of how many you got right does not translate into a grade.

None of this tests clinical knowledge. It marks judgement against three professional values: empathy and sensitivity, professional integrity, and coping with pressure. A candidate who reads it as a knowledge paper and looks for the medically correct action is answering the wrong question.

Most items resolve to a small set of principles, weighed against each other rather than applied one at a time.

• Patient safety first — whatever protects the patient from harm outranks whatever protects a relationship, a schedule, or someone's feelings.
• Honesty and openness — the more truthful, transparent action usually outranks one that avoids an awkward conversation.
• Escalate appropriately rather than act beyond your competence — involve the right person at the right level, neither doing something yourself that is not yours to do, nor going over someone's head when a word to them would do.
• Involve the person the dilemma concerns — a patient or colleague is generally told what is happening and asked, not managed around.
• Do not ignore a concern or leave it for someone else to deal with — passing a problem along unaddressed is rarely the top-ranked response.
• Act, do not just avoid — the safest-sounding option is often the one that does nothing, and doing nothing is usually not top of the list.

The skill the paper tests is weighing these against each other when they pull in different directions — safety against sensitivity, honesty against escalation — not reciting any one of them.

• Treating it as a knowledge test. There is no clinical fact to recall here; the paper marks reasoning about people and process, not medicine.
• Picking the most dramatic-sounding option. The most decisive-looking action is not automatically the most appropriate one — proportion matters as much as intent.
• Over-escalating. Jumping straight to the most senior person or the most formal process available, skipping every proportionate step in between, tends to score worse than it feels like it should.
• Getting the middle of the ranking wrong. The best and worst responses in a five-item ranking are usually easy to place; separating several reasonable-but-imperfect actions in between is where strong candidates pull ahead.

The scenario below was written for this guide to illustrate the reasoning. It is not a released MSRA item, and no resemblance to one is intended.

A foundation doctor notices that a trainee they are working alongside has come into two consecutive night shifts smelling of alcohol from the evening before. The trainee has performed competently and no patient has come to harm. Asked if they are alright, the trainee brushes it off: 'fine, just been letting off steam.'

• Say nothing, since no patient has been harmed and it is not really your business.
• Report the trainee to the regulator directly, without raising it with anyone locally first.
• Raise the smell of alcohol with the trainee in front of the rest of the team, to make sure the concern is heard.
• Speak to the trainee privately, express concern for their wellbeing, and separately flag the pattern to your clinical supervisor as a safety concern that needs following up.

The first response ignores a concern rather than acting on it. The third breaches sensitivity for the sake of being seen to act, and risks the trainee's dignity for no real safety gain. The second does act, and does put safety first, but skips every proportionate local step — the supervisor, occupational health, a private conversation — in favour of the most formal route available, which is not the same as escalating appropriately. The fourth does the most of the six principles at once: it involves the person concerned, it is honest without being public, it treats a patient-safety risk as one, and it escalates to the right level rather than either doing nothing or going over everyone's head. That is the reasoning a ranking item is built to reward — a weighing you carry out, not a fact you look up.

Practising Professional Dilemmas well means practising the reasoning behind an item, not trying to memorise a fixed set of correct-sounding answers to recall on the day. Work every scenario from the principles above before you look at the options, and check your reasoning against the outcome rather than just the score.

This is how SpecialityMCQs treats Professional Dilemmas: practice items are drawn into sessions alongside Clinical Problem Solving on a blueprint-weighted basis, tilted toward whichever paper is currently costing you marks, with misses returning on a spacing schedule rather than being seen once and forgotten. Every answer names the reasoning it rests on. Five new questions a day are free, with no card required.