Master Professional Dilemmas (SJT)
for MSRA

What the MSRA Tests in Professional Dilemmas (SJT)

The MSRA Situational Judgement Test (SJT) in Professional Dilemmas assesses your ability to apply the GMC's 'Good Medical Practice' framework to realistic clinical scenarios. You will be tested on recognising and managing conflicts of interest, consent (including Gillick competence and Mental Capacity Act 2005), confidentiality breaches, fitness to practise (including impairment from alcohol, drugs, or cognitive decline), and whistleblowing. Scenarios often involve a colleague with suspected substance misuse (e.g., opioids, alcohol), a patient refusing life-saving treatment (e.g., blood transfusion for Jehovah's Witness), or a trainee struggling with competence. You must demonstrate knowledge of local policies (e.g., incident reporting via Datix, occupational health referrals) and legal duties (e.g., disclosing a serious communicable disease to a partner under public health law).

High-Yield Concepts

• GMC Good Medical Practice (2013) – Four Pillars of Ethical Practice: Prioritise patient safety, maintain trust, show respect for patients, and work in partnership. Always put patient safety above hierarchy. For example, if a senior prescribes an incorrect dose of gentamicin (e.g., 7 mg/kg once daily in renal impairment), you must escalate through the chain: speak directly to the prescriber, then to the consultant, then to the clinical director, and finally to the GMC if no action is taken.
• Mental Capacity Act 2005 – Five Principles: Assume capacity unless proven otherwise. A patient with capacity can refuse even life-saving treatment (e.g., a 45-year-old with acute leukaemia refusing chemotherapy). If capacity is in doubt, use the two-stage test: (1) is there an impairment of mind or brain? (2) does that impairment prevent them from understanding, retaining, weighing, or communicating a decision? For a patient with delirium secondary to pneumonia, you may treat under 'best interests' after a formal capacity assessment.
• Consent – Gillick Competence for Minors: A child under 16 can consent if they have sufficient understanding and intelligence (Gillick competent). For example, a 14-year-old requesting the contraceptive pill can consent without parental involvement if they understand the risks and benefits. However, if they refuse treatment (e.g., a 15-year-old with type 1 diabetes refusing insulin), parental consent can override if the child is not deemed Fraser competent, but court involvement may be needed.
• Confidentiality – Disclosures Without Consent: You can breach confidentiality without consent in three situations: (1) patient consent, (2) public interest (e.g., a patient with active TB refusing treatment and putting others at risk), (3) court order. For a patient with HIV who refuses to inform their partner, you may disclose to the partner if they are at serious risk of infection and the patient cannot be persuaded. Always document your reasoning and inform the patient first.
• Fitness to Practise – Impaired Colleague: If you suspect a colleague is impaired by alcohol, drugs, or mental health issues (e.g., a surgeon with hand tremors from alcohol withdrawal), you must act. First, speak to the colleague informally. If no change, escalate to the clinical lead or medical director. Use occupational health for assessment. Do not ignore it. If the colleague is an immediate risk (e.g., intoxicated during a procedure), remove them from duty and call the consultant on call.
• Whistleblowing – Raising Concerns: You have a duty to raise concerns about patient safety (e.g., a nurse consistently failing to check patient IDs before giving medications). Follow local policy: speak to the individual, then line manager, then trust's Freedom to Speak Up Guardian. If no action, escalate to the CQC or GMC. The law protects whistleblowers from detriment. Do not wait for proof; raise concerns based on reasonable suspicion.
• Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Decisions: DNACPR decisions must be made in consultation with the patient (if they have capacity) or their family (if not). For a patient with end-stage COPD (e.g., FEV1 < 30% predicted) and recurrent admissions, a DNACPR form should be completed by the responsible consultant. Never place a DNACPR without discussion unless it would cause physical or psychological harm. The form must be reviewed regularly and is not the same as 'not for treatment'.
• Research Ethics – Consent and Data Protection: For research involving human participants (e.g., a trial of a new anticoagulant in atrial fibrillation), you must obtain written informed consent after explaining risks, benefits, and alternatives. Data must be anonymised per GDPR. If a patient withdraws consent, their data can still be used if already analysed, but no further data should be collected. The local Research Ethics Committee (REC) must approve all studies.

Common Traps in Professional Dilemmas (SJT) Questions

• Confusing 'best interests' with 'what the doctor thinks is best' – best interests include the patient's past wishes, beliefs, and values, not just medical opinion.
• Thinking you can always breach confidentiality if a patient has a serious communicable disease – you must first try to persuade the patient to inform partners and only disclose if there is a serious and identifiable risk.
• Assuming a child under 16 can never consent to treatment – Gillick competence applies, and a 14-year-old may consent to contraception but not necessarily to a major surgery.
• Believing that a DNACPR order means 'do not treat' – it only applies to cardiopulmonary arrest; all other treatments (e.g., antibiotics, fluids) should continue as appropriate.
• Failing to escalate a concern because you are junior or fear repercussions – the GMC expects all doctors to act on patient safety concerns regardless of hierarchy.

How to Revise Professional Dilemmas (SJT) for the MSRA

Focus on the GMC's 'Good Medical Practice' as your absolute framework. Questions are scenario-based with five response options ranked from 'most appropriate' to 'least appropriate'. Prioritise patient safety, consent, and confidentiality above all else. Practise distinguishing between 'inform the patient' vs 'inform the partner' in confidentiality dilemmas. Memorise the Mental Capacity Act principles and the two-stage test. For colleague impairment, always escalate stepwise: informal talk, then line manager, then occupational health. Use the 'ABCD' approach: Act, Be safe, Communicate, Document. Review the GMC's 'Raising Concerns' guidance and the BMA's ethics toolkits.

Practise it: MedLumen has 50 Professional Dilemmas (SJT) questions for the MSRA, each with a full explanation and references.