Most MSRA candidates prepare for the exam as a single entity: work through a question bank, do some situational judgement practice near the end, sit the paper. That approach systematically underperforms, because the MSRA is not one exam with two sections. It is two genuinely different assessments, testing different capabilities, scored by different logic, and sat back to back in a single sitting. Preparing for them as one thing means preparing properly for neither. Here is why they need separate systems, and how to build them.
Key takeaways
- Professional Dilemmas is sat first: 50 scenarios in 95 minutes, testing judgement rather than knowledge.
- Clinical Problem Solving comes second: 97 questions in 75 minutes, which is under 50 seconds per item.
- The two papers are scored differently, and PD's near-miss key means a partially correct answer still earns marks.
- Track your performance on each paper separately, because one combined percentage hides which one is sinking you.
- Neither paper has negative marking, so leaving anything blank is the one guaranteed way to lose marks.
Two exams, not two halves
Understand what you are actually sitting. The Professional Dilemmas paper comes first, and it is a situational judgement test: 50 scenarios in 95 minutes, in which you either rank a set of actions from most to least appropriate, or select the three most appropriate responses from a list of eight. It assesses professional behaviour at foundation level, not clinical knowledge. After an optional five-minute break, the Clinical Problem Solving paper follows: 97 questions in 75 minutes, a mix of extended matching questions and single best answers, testing applied clinical decision-making across the breadth of medicine.
Those two descriptions have almost nothing in common. One tests whether you know what a good doctor does when a colleague appears impaired; the other tests whether you know the first-line investigation in suspected pulmonary embolism, and whether you can decide it in forty-six seconds. Revising for them with the same method is like training for a marathon and a chess tournament with the same session.
The pacing problem nobody prepares for
Do the arithmetic on the clinical paper, because it explains a great deal of underperformance. Ninety-seven questions in seventy-five minutes is roughly forty-six seconds per item, including reading the stem, working through an extended matching set, and committing. That is dramatically faster than most candidates ever practise, and it is faster than almost any other exam they have sat.
Now add the sequencing. You do not arrive at that paper fresh. You arrive after ninety-five minutes of dense, cognitively demanding judgement scenarios, with a five-minute break. Candidates who have only ever practised clinical questions untimed, in the evening, with the explanation open, discover this on the day. Practise the pacing specifically, and practise it tired.
Why the scoring logic changes the strategy
The two papers reward different behaviour, and this is where separate systems really matter.
The clinical paper scores conventionally: one mark per correct answer, no negative marking. Answer everything, guess where you must, move on.
The Professional Dilemmas paper is scored against a pre-determined key using a near-miss approach, meaning your answer earns marks according to how closely it matches the expert consensus rather than being simply right or wrong. On a ranking question, even a substantially imperfect order still earns partial credit, while a skipped question earns nothing at all. The practical consequence is stark: on PD, an imperfect attempt is always worth more than a blank, and candidates who run short of time and leave items unanswered are throwing away marks they would have earned by guessing.
Track them separately
The single most useful change most candidates can make is to stop looking at one combined percentage. Keep two dashboards.
Your clinical performance should be tracked the way you would track any knowledge-based bank: accuracy by topic, coverage across the twelve clinical areas, and speed. Your PD performance needs different measures entirely, because there is no topic list to cover. What matters there is whether your judgement is consistently aligned with the professional standard, and where it systematically diverges: are you consistently too willing to manage things yourself rather than escalate, or too quick to involve seniors, or reluctant to raise a concern about a colleague?
A single combined score hides all of this. A candidate at the seventy-fifth percentile clinically and the forty-fifth on judgement, and one who is solidly mid-table on both, can produce a similar total while needing completely different remedies.
Build the PD system early, not late
The commonest error is treating Professional Dilemmas as the paper you cram in the final fortnight. It carries substantial weight in your total score, and it is the paper where structured preparation produces the largest improvement, precisely because most candidates neglect it.
Its foundation is not a question bank at all. It is the professional framework the questions are written against: the GMC's expectations of a doctor, the escalation norms of an NHS team, and the standards around candour, confidentiality and patient safety. Read that framework first, then practise scenarios, then review not just whether you were right but why the expert consensus ranked as it did. That reasoning is the transferable skill, and it needs weeks, not days.
Where iatroX fits
iatroX's MSRA bank covers the clinical side of the exam with questions mapped to the clinical topic areas and explanations grounded in NICE, CKS, SIGN and the SmPC, with an adaptive engine that targets the topics where you are actually weak and spaced repetition to hold a broad curriculum together. Missed questions can be opened in the Socratic Tutor, which asks you to reason before it explains. Practise the judgement paper separately, with dedicated situational judgement material and the professional framework it is built on, and keep the two dashboards apart. Try the clinical side with free sample questions at iatroX. For the errors that cost most marks on the clinical paper, see MSRA clinical problem solving errors.
Frequently asked questions
Which MSRA paper comes first? Professional Dilemmas is sat first, with 50 scenarios in 95 minutes, followed by an optional five-minute break and then Clinical Problem Solving, with 97 questions in 75 minutes. The whole assessment runs to 170 minutes.
Is there negative marking in the MSRA? No, on either paper. Leaving an item blank guarantees zero marks for it, whereas an imperfect answer on the ranking questions still earns partial credit under the near-miss key. Attempt everything.
Why do candidates run out of time on the clinical paper? Because 97 questions in 75 minutes is under 50 seconds per item, far faster than most candidates ever practise, and it comes after 95 minutes of demanding judgement scenarios. Practise the pacing under timed conditions, and practise it when tired.
Should I prepare for Professional Dilemmas with a clinical question bank? No. It tests professional judgement rather than clinical knowledge, and clinical reasoning applied to a judgement scenario reliably underperforms. Start from the professional framework, then practise scenarios in the exam's own formats.