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MSRA Exam Overview

The MSRA is comprised of two separate papers which examine two very different skillsets:

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How is the MSRA used to allocate training posts?

The MSRA score is used to assign invitations to interviews and allocate offers for 12 different speciality training pathways. Each of the 12 specialities that include the MSRA in their application process uses your exam score differently. For many specialities, the invitation to interview is entirely governed by the candidate’s MSRA score. After interviews, the MSRA score also commonly contributes to a candidate’s overall score, which is used to allocate offers. Those with the highest combined scores achieve a training post at their desired geographical location. See the table below* to understand how each speciality uses the MSRA score in their application process.

Training Program	How interviews are allocated:	How offers are allocated:
ACCS Emergency Medicine	100% MSRA	40% MSRA + 60% Interview
Anaesthetics	100% MSRA	15% MSRA + 85% Interview
Clinical Radiology	100% MSRA	MSRA + Portfolio + Interview
Community Sexual and Reproductive Medicine	100% MSRA	100% Interview
Core Surgical Training	100% MSRA	10% MSRA + 30% Portfolio + 60% Interview
Core Psychiatry Training	N/A	100% MSRA
General Practice	N/A	100% MSRA
Neurosurgery	Portfolio + MSRA	Portfolio + MSRA + Interview
Nuclear Medicine (ST3)	100% MSRA	MSRA + Portfolio + Interview
Obstetrics and Gynaecology	100% MSRA (if you score highly enough you will bypass interviews and be given an offer)	33.3% MSRA + 66.7% Interview
Ophthalmology	100% MSRA	MSRA + Portfolio + Online Assessment

*Disclaimer: This information is subject to change. Consult your specialties’ national recruitment office website for more information.

How is the MSRA graded?

The MSRA is a competitive exam. Scores are scaled relative to other candidates who have taken the exam in the same application year. Scores are scaled to an average score of 250 with a standard deviation of 40. Candidates are placed in a ‘band’ depending on your score as shown below. (Source Health Education England)

It is also worth noting that the weight given to the Professional Dilemmas and Clinical Problem-solving sections varies depending on the speciality for which the candidate is applying. For example, in General Practice and Psychiatry, the Professional Dilemmas paper carries more weight than the Clinical Problem-solving section, whereas the two components are weighted equally in Emergency Medicine.

Table 1: Professional Dilemmas Paper Scoring Bands:

Standardised score range	Percentage scoring in this range	Score band	Score meaning
Below 170	5%	1	Very Poor Performance
171-185	5%	1	Very Poor Performance
186-210	18%	2	Below average Performance
211-230	21%	2	Below average Performance
231-250	19%	3	Good Performance
251-270	16%	3	Good Performance
271-290	11%	3	Good Performance
291-310	4%	4	Very Good performance
Above 310	1%	4	Very Good performance

Table 2: Clinical Problem Solving Paper Standardised Bands

Standardised score range	Percentage scoring in this range	Score band	Score meaning
Below 170	3%	1	Very Poor Performance
171-185	3%	1	Very Poor Performance
186-210	9%	2	Below average Performance
211-230	13%	2	Below average Performance
231-250	19%	3	Good Performance
251-270	23%	3	Good Performance
271-290	20%	3	Good Performance
291-310	9%	4	Very Good performance
Above 310	1%	4	Very Good performance

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Professional Dilemmas Paper Breakdown:

The Professional Dilemmas paper consists of 50 Situational Judgment scenarios that assess your ability to deal with ethical and professional dilemmas that arise in the workplace. For this section of the exam, you must assume the role of an FY2 (unless stated otherwise).

The exam contains two different question types (ranking and multiple choice) which require two very different exam strategies:

Ranking questions

Example Question:

You are a Foundation (F2) doctor working in respiratory medicine. You are reviewing
Eileen, who has been admitted to hospital three times in the last 6 months, with exacerbations of Chronic Obstructive Pulmonary Disease. She tells you that she has been advised to stop smoking but is finding it difficult to do so because she worries a lot about her 25-year-old daughter, Kirsty, who has financial difficulties. Eileen says that she works overtime to try to support Kirsty.

Rank in order the following actions in response to this situation
(1=Most appropriate; 5= Least appropriate).

A. Advise Eileen that she must give up smoking for her health.
B. Inform Eileen that if she continues to smoke, her health may deteriorate and she may not be able to work at all.
C. Suggest to Eileen that it would be beneficial to explore ways to manage her worries.
D. Ask Eileen whether Kirsty has sought professional financial advice.
E. Suggest to Eileen that Kirsty should not be causing her to put her health at risk.

Our Stepwise approach to rationalising ranking questions:

1. Identify the core issue or the root cause: First identify the core issue or the root cause of the issue outlined in the scenario. Once you have identified the central issue or the root cause you can judge the proposed answers based on whether they address this or not.
   
2. Rank the best option in place first: If you can correctly identify the best and worst options, because of the way that the questions are marked, the lowest you can score on the question in 16/20. Therefore, once you have identified the core issue, identify the best option. This will be the answer which addresses the core issue in the most DIRECT and TIMELY manner.
   
3. Next, identify the worst option: Once you have selected the best option, find the worst answer. You can identify the worst option if it directly contradicts GMC Guidelines or ignores the core issue completely.
   
4. Sort the middle pack into ‘Somewhat Appropriate’ and ‘Somewhat Inappropriate’: This is the hardest bit. Applicants often compare the middle pack to each other instead of judging them as individual answers, which looses you marks. A useful way to approach it is to assign ‘Somewhat Appropriate’ and ‘Somewhat Inappropriate’ labels to these answers which are left. A ‘Somewhat Appropriate’ answer often aims to address the core issue in the scenario but has a detracting factor. This may be that it lacks an element of empathy, directness or diplomacy. In contrast, the ‘Somewhat Inappropriate’ answer is a fundamentally inappropriate way to address the scenario but still has a positive aspect: such as addressing a secondary issue or attempting to work towards a solution, but in a inappropriate way.
   
5. Sense Check: Sense check your answers against the scenario. Again, avoid comparing the options to one another, instead ask yourself: Does my first option address the core issue in a direct and timely way? Does my last option go against a GMC principle or add nothing to solving the main issue? In the middle pack, do the more appropriate options focus on the core issue with a minor detracting factor?

MedicRecall Ranking Flow-Chart

Worked Example:

Let’s work through the example question mentioned earlier to demonstrate how to use the 5-step flow-chart:

1. Identify the core issue or the root cause:
The core issue is that Eileen is not able to quit smoking despite previous attempts and this is having a negative impact on her health. The root cause of this issue is that she has been unable to cope with social stressors in a healthy way, so turns to smoking.

2. Rank the best option:
The best option in this scenario is C. This is because improving Eileen’s ability to cope with stressors targets the root cause in an appropriate and direct manner. Even irrespective of social issues, she is empowered to stop smoking in the long-term.

3. Rank the worst option:
The worst option is A. When you take this action in isolation, re-iterating to Eileen that she needs to quit smoking for her health, when she has already been told this previously, does not address Eileen’s inability to quit (core issue) or ability to cope with stressors (root cause). It goes against GMC principles regarding empathy and sensitivity, ignoring the social concerns she has shared with you.

4. Sort the middle pack into ‘Somewhat Appropriate’ and ‘Somewhat Inappropriate’
Out of the options left, the only answer which targets the root cause in a ‘Somewhat Appropriate’ way is D. Suggesting financial support is a holistic approach which could alleviate Eileen’s main social stressor and mean that she is more capable of quitting smoking. However, it is not a direct or long-term solution. Both B and E fall in the ‘Somewhat Inappropriate’ category. Option B is overall an inappropriate way of motivating a patient to make a lifestyle change. Despite approaching the issue in the wrong way, this action does have a chance of having the correct outcome. In contrast, option E misses any opportunity to motivate Eileen to stop smoking it’s small redeeming factor being that you are acknowledging part of the root cause even if you fail to help address it.

5. Sense Check
Now you have your ranking: CDBEA
Ask yourself: Does my first option address the core issue in a direct and timely way? Does my last option go against a GMC principle or ignores the main issue? In the middle pack, do the more appropriate options focus on the core issue with a minor detracting factor?

This may seem like a time-consuming way of answering ranking question but with practice, it will become second nature!

How are Ranking questions Scored?

Ranking questions are scored against a pre-determined key, which factors in near misses (see the table below for and example). If the ideal answer was ABCDE and the candidate submitted ACDBE, they would score 4+3+3+2+4 = 16 (see below). Notice that for this question, the candidate correctly identified the best and worst option but got the middle pack completely wrong, but still scored 16/20 (80%).

Multiple Choice Questions

The ‘Pairing Off’ Technique

The Paring off technique is where you ‘pair off’ two options which target the same part of the scenario and wouldn’t make sense if you did both of them together. Once you have a pair, you can then eliminate the least appropriate option.

Please Note: The technique does have it’s limitations. Scenarios often cannot be neatly rationalised into 4 different pairs.

Paring Off Technique Worked Example:

You are an FY2 on a busy respiratory ward and you are working with two other Foundation Year doctors. You feel that the workload is not being shared appropriately between you and that you are being left with all the ward jobs e.g. discharge summaries and the other Foundation Year doctors are able to work on audit projects and observe procedures.

Choose the THREE most appropriate actions to take in this situation.
A: Organise a meeting with the other Foundation Year doctors and the lead consultant on the ward about this issue.
B: Discuss the situation with your speciality trainee (registrar) to ask for advice.
C: Refuse to do any more discharge summaries until the workload is shared more evenly.
D: Speak to the lead consultant if it continues after you have raised the issue with your Foundation Year colleagues.
E: Approach both Foundation Year colleagues about this issue and ask for their perspectives.
F: Ask your educational supervisor to speak with your Foundation Year colleagues about the issue.
G: Ask the Foundation Year doctors to complete some of your discharge summaries to even the workload
H: Speak to a friend working on another ward about the situation.

Several of these actions can be paired off into groups that focus on achieving the same thing but in different ways:
Group 1: Meet with your FY colleagues
A: Organise a meeting with the other Foundation Year doctors and the lead consultant on the ward about this issue.
E: Approach both Foundation Year colleagues about this issue and ask for their perspectives.
Group 2: Ask for advice
B: Discuss the situation with your speciality trainee (registrar) to ask for advice.
H: Speak to a friend working on another ward about the situation.
Group 3: Escalation
D: Speak to the lead consultant if it continues after you have raised the issue with your Foundation Year colleagues.
F: Ask your educational supervisor to speak with your Foundation Year colleagues about the issue.
Group 4 – Miscellaneous
C: Refuse to do any more discharge summaries until the workload is shared more evenly.
G: Ask the Foundation Year colleagues to complete some of your discharge summaries to even the workload

Group 1 – Both options here are asking for a meeting with your colleagues to address this problem (an appropriate thing to do). However, it would be more appropriate at this stage to resolve this issue directly with your Foundation Year colleagues. If this can be solved amongst yourselves, there is no need to involve the consultant and escalate the scenario unnecessarily – making E the best option in this group.

Group 2 – Each option deals with who you should seek advice from. Speaking with your speciality trainee for advice is a better option than a friend on a different ward. Your speciality trainee will have a much better insight into your team dynamics and how jobs should be allocated, making them the better person to get advice from.

Group 3 – These options are about escalating this issue to a senior. It would be appropriate to raise this with your consultant if the issue persists despite a reasonable attempt at local resolution. This is much more preferable option compared with asking your educational supervisor to intervene on your behalf (your consultant is also better placed than your educational supervisor to address this issue).

Group 4 – These answers do not fall into an obvious group. Still, you should be able to identify these as incorrect answers, especially as you have already identified three good answers that can be taken together. You should not address the problem by being passive-aggressive (G) or going on strike until things change (C).

Check your answer:
You can then check your answer by using AND between each option. ‘I would discuss the situation with my speciality trainee (registrar) to ask for advice AND I would approach my Foundation Year colleagues directly AND Speak to the lead consultant on the surgical ward if it continues after approaching those involved directly. These options fit together well and address the problem at hand in a proportional and appropriate manner. Therefore, we can reason that the answer is EBD.

How are Multiple Choice questions scored?

The scoring for multiple choice questions is simple:
4 marks are awarded for each correct answer to a maximum of 12.

Therefore, the majority of the marks in the Professional Dilemmas paper are allocated to the ranking questions (each ranking question has a maximum score of 20).

How to prepare for the Professional Dilemmas Paper

In order to achieve an excellent score in the Professional Dilemmas paper you need good exam technique combined with a strong foundation of knowledge which is aligned how the GMC and NHS England want you to manage difficult scenarios.

Therefore, your preparation needs to be closely aligned with official content released by the GMC and NHS England. Most other preparation platform or question banks offer low-quality, self-generated questions which often deviate from official guidelines and can confuse your thinking process.

At MedicRecall, our platform only contains high quality content aligned with official guidelines. We have combined this content with efficient learning techniques to help candidates rationalise questions just like the exam-writers do.

To learn more about how preparing for the Professional Dilemmas Paper or to sign up to MedicRecall, click below!

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Clinical Problem-Solving Paper Breakdown

The Clinical Problem-Solving paper consists of 97 multiple-choice questions that evaluates the candidate’s ability to diagnose and manage medical conditions. The questions contain short clinical scenarios and cover a wide range of medical specialities.

This part of the exam tests your medical knowledge in 12 specialities. The emphasis here is a good BREADTH of knowledge rather than DEPTH.

Specialities tested:

Question types:

Extended Matching questions – You are given 7-10 plausible answers to match with 4-5 clinical questions.
Multiple choice questions – These are single best-answer questions, with 5-8 possible options.

These two question types are weighted equally in the exam, so each makes up approximately 50% of the marks for the Clinical Problem-Solving paper.

What do the questions examine you on?

• Investigation: Specific investigations that are carried out in order to obtain a more conclusive diagnosis or rule out possible causes of illness/injury.
• Diagnosis: Identification of a condition, disease or injury made by evaluating the symptoms and signs presented by a patient.
• Emergency: Potential serious illness requiring an immediate response (recognising patient risk based on suggested factors).
• Prescribing: Advising, authorising or reviewing the use of medicine/drugs as part of a patient’s clinical management plan.
• Management (non-prescribing): Advising, authorising or reviewing the use of other forms/methods of treatment (not medicinal/drug-related) as part of a patient’s clinical management plan. (Source)

How to Prepare for the Clinical Problem-solving Paper?

For the clinical Problem Solving paper, preparation is more straight forward. Our recommendation is sign-up to a trusted question bank and focus on breath of content and efficient learning techniques.

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Booking the exam

Applications are managed on Oriel. https://www.oriel.nhs.uk/Web
New change for 2025: applicant are only permitted to submit applications to a maximum of 5 different specialities

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What is the exam day like?

The MSRA is generally run as an in-person exam at PearsonVue test centres. Only in exceptional circumstances can the exam be done remotely. The exam is held at test centres across the UK.

Upon arrival at the centre, you must sign in and present your photo ID at the front desk. The receptionist will then ask you to lock up all your belongings except your snack and water bottle. Depending on when you arrive, you will be asked to wait in a waiting room before your scheduled time slot begins. After being called into the testing area, you will be given a whiteboard and a pen by the attendant. You will also be offered earplugs at most test centres. Then, you will be escorted to your desk. At your desk, you will find a standard computer equipped with over-ear headphones. We recommend wearing the headphones provided for the entire exam to block out background noise and allow you to focus on the task at hand.

After 95 minutes have passed for the Professional Dilemmas paper, you will receive a pop-up option asking whether you would like to take a 5-minute optional break. Click yes to this option if you want to take the break, then raise your hand to the invigilator, who ensures the test is paused and lets you out of the exam room. You are free to leave the building during your break and get access to your locker. During your break, you can have a snack, drink, toilet break, or get some fresh air. However, please ensure that you are back on time. If you take longer than 5 minutes, the exam will restart automatically, and this will eat into your time to complete the Clinical Problem-Solving paper. Make a note of the time you left (remember that you won’t have a watch with you) and come back with a couple of minutes to spare.

Each section of the exam is treated as a separate entity. Therefore, if you finish the Professional Dilemmas paper early and click onto the Clinical Problem-Solving paper, your extra time does not roll over and you will still have only 75 minutes to complete the Problem-Solving paper. Additionally, once you have started the Clinical Problem-Solving paper, you cannot change your answers to the Professional Dilemmas questions.

There is no cost to sitting the MSRA. However, candidates are only able to sit the exam once per application year, and their score will only be valid for 12 months. Booking of the MSRA is completed via the PearsonVue website, where you can reserve a slot to attend one of their test centres. The most desirable slots can often ‘sell out’ quickly, so you should book soon after the release date.

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Exam timings and structure:

The exam is 170 minutes in total, with an optional 5-minute break. The break is situated between the Professional Dilemmas paper (95 minutes) and the Clinical Problem-Solving paper (75 minutes). Taking the 5-minute optional break does not impact the amount of time you are given to complete the clinical problem-solving paper. However, if you do not restart the exam within 5 minutes, the excess time will be taken out of the 75 minutes you have to complete the clinical problem-solving part of the exam.

You can flag questions that you are unsure about for review. Therefore, at the end of each section, you have the opportunity to review flagged questions. We recommend changing an answer only if you believe you have gained a new insight that you did not consider when you first tackled the question. Otherwise, trust your instincts if you’re still unsure.

For the Clinical Problem-Solving paper, ensure you are on target to finish on time by completing at least 50/97 questions once 35 minutes have elapsed. If you are short of this, you can pace the rest of the exam accordingly. These numbers can be adjusted for those with extra time by adding 25% to each section, but the same principles apply.

Thank you for reading our complete MSRA Exam Guide. Sign up to MedicRecall and ace Professional Dilemmas Paper by thinking like the exam-writers do!