Dr Kola Tytler (MBBS CertHE MBA MRCGP)|21 April 2026|7 min read
The Professional Dilemmas paper is 50% of the total MSRA score. It contains approximately 32 scenarios, each presenting a clinical or professional situation where you must rank or rate the appropriateness of several actions. It is the single most under-prepared component of the MSRA, and for many candidates, it is the paper that determines their band.
This guide covers the question formats, the underlying framework, the best resources, and a practical daily strategy for SJT preparation.
Why the SJT Matters More Than You Think
Consider the maths. The MSRA has two papers, weighted roughly equally. A candidate who scores excellently on CPS but averagely on Professional Dilemmas will end up with a mid-range overall score. A candidate who scores well on both papers — even if their CPS score is slightly lower — will often rank higher overall.
The SJT is also the paper where preparation yields the most return. CPS tests clinical knowledge accumulated over years of medical school and foundation training — it is difficult to move the needle significantly in a few weeks. SJT tests reasoning skills and framework application that can be learned and practised in a structured way. Candidates who dedicate serious time to SJT preparation consistently report the largest score improvements.
Question Formats
The Professional Dilemmas paper uses two question formats.
Ranking questions present a scenario and ask you to rank 4–5 actions from most appropriate to least appropriate. You receive full marks for the correct ranking and partial marks for rankings that are close to correct. The scoring is generous for rankings that are within one or two positions of the correct answer.
Rating questions present a scenario and ask you to independently rate each of 4–5 actions on a scale from 1 (most appropriate) to 5 (least appropriate). Each action is scored independently — your rating of Action A does not affect your marks for Action B.
Understanding the difference between these formats is important because your strategy differs. For ranking questions, the relative ordering matters — focus on identifying the absolute best and absolute worst actions first, then order the middle. For rating questions, each action is judged in isolation — focus on whether each specific action is appropriate, rather than comparing them to each other.
The Underlying Framework
Every Professional Dilemmas question is ultimately testing your understanding of GMC Good Medical Practice and the principles of medical ethics. The framework can be distilled into a hierarchy of priorities.
Patient safety is always the top priority. Any action that protects a patient from harm should be ranked highly. Any action that delays addressing a safety concern should be ranked low.
Escalation is almost always appropriate. When in doubt, escalating to a senior colleague or reporting through the correct channel is a safe choice. The SJT rarely penalises appropriate escalation.
Covering up, ignoring, or delaying is almost always wrong. Turning a blind eye to a colleague's impairment, ignoring a prescribing error, or deciding to "wait and see" on a patient safety issue are consistently the least appropriate actions.
Maintaining professional boundaries matters. Actions that are well-intentioned but cross professional boundaries (treating a family member, giving personal contact details to a patient, diagnosing a colleague informally) are typically rated lower than candidates expect.
Communication is valued over unilateral action. Discussing concerns with a colleague before escalating, explaining your reasoning to the patient, and seeking consensus within the team are generally rated higher than acting alone.
The Best SJT Resources
The SJT resource landscape is uneven. Some platforms treat Professional Dilemmas as an afterthought — tacking on a handful of SJT questions to a primarily clinical Q-bank. Others have invested heavily in SJT-specific content. The differences matter.
Emedica has the strongest reputation for SJT question quality. Its Professional Dilemmas content is frequently cited by candidates who score 600 and above as the single most valuable MSRA resource. The questions are challenging, well-constructed, and closely mirror the reasoning required in the real exam. If you use only one paid resource specifically for SJT, make it Emedica.
Pass the MSRA has the most comprehensive SJT resource package. It offers a dedicated SJT Q-bank, 10 SJT mock papers (500 questions), a free 100-page SJT textbook (downloadable without subscription), a YouTube channel with SJT strategy content, and a Spotify podcast. The free SJT textbook alone is worth downloading — it covers frameworks, worked examples, and common pitfalls.
Revise MSRA offers 250 dedicated Professional Dilemmas questions with specific preparation materials. As a dedicated MSRA platform, its SJT content is well-integrated with the clinical revision experience.
PassMedicine includes 300 Professional Dilemma questions. Solid but not the headline strength — PassMedicine's primary value proposition is CPS volume and the Knowledge Tutor textbook.
iatroX includes Professional Dilemmas questions in its free MSRA bank. The adaptive mode identifies weak areas in ethical reasoning and resurfaces relevant scenarios. The clinical AI can be used to explore the GMC guidance behind a specific question — for example, asking "What does GMC Good Medical Practice say about reporting concerns about colleagues?" and receiving an instant, cited answer.
Daily Practice Strategy
Begin SJT preparation from the start of your revision period, not the end. The skills take time to develop.
In weeks 1–4, do 5–10 SJT questions per day in revision mode. Read every explanation carefully — focus on understanding the reasoning, not just the correct answer. When you disagree with the model answer, look up the relevant GMC guidance to understand the framework.
In weeks 5–6, increase to 15–20 SJT questions per day. Begin doing them under timed conditions. The real exam allocates approximately 3 minutes per Professional Dilemmas scenario — practise working at this pace.
In weeks 7–8, do full-length Professional Dilemmas mock papers under timed conditions. Review every incorrect answer and create a list of "principles I keep getting wrong" — this is your most valuable revision asset in the final week.
Common SJT Traps
The "helpful but wrong" trap is the most common. An action can sound helpful and compassionate but be professionally inappropriate. Offering to counsel a distressed patient yourself when the correct action is to refer to the appropriate team is a classic example — it prioritises your desire to help over the patient's best interest.
The "harsh but right" trap is the inverse. Reporting a colleague to a supervisor or regulatory body can feel harsh, but if patient safety is at risk, it is the correct action. The SJT consistently rewards decisive, safety-first responses.
The "discuss first" principle catches many candidates. When you suspect a colleague is underperforming, the first step is almost always to discuss your concerns with them directly (unless the situation is so urgent that immediate escalation is required). Going straight to a formal report without attempting a conversation first is usually rated as less appropriate than raising the issue directly.
Using iatroX for SJT Preparation
iatroX's MSRA bank includes Professional Dilemmas questions that benefit from the adaptive algorithm — when you consistently misapply a particular ethical principle, the platform resurfaces scenarios testing that principle until your reasoning aligns with the framework.
The Ask iatroX feature provides a unique advantage for SJT preparation. When you encounter a scenario where the model answer surprises you, you can immediately query the clinical AI for the relevant GMC or NICE guidance. For example: "What are the GMC principles on maintaining professional boundaries with patients?" — and receive a synthesised, cited answer. This closes the loop between question practice and framework understanding in a way that traditional Q-bank explanations cannot.
The Bottom Line
The Professional Dilemmas paper is 50% of the MSRA. It is the paper where structured preparation yields the most improvement. Start early, practise daily, learn the frameworks, and invest in at least one high-quality SJT resource. The marks gained from strong SJT preparation often exceed the marks gained from additional CPS revision.
Information based on public sources as of 21 April 2026. Trademarks belong to their owners.