Master Professional Dilemmas (SJT)
for MSRA

Core Concepts

The Situational Judgement Test (SJT) section of the MSRA assesses your understanding of appropriate behaviour for a doctor, focusing on professional attributes, values, and behaviours, rather than medical knowledge. It evaluates your ability to make sound judgements in challenging professional scenarios. Core principles are primarily derived from the GMC's Good Medical Practice (2024), which serves as the fundamental ethical framework for doctors in the UK. Key concepts include:

• Patient Safety First: The paramount consideration in all decisions.
• Ethical Pillars: Autonomy (patient's right to make decisions), Beneficence (acting in the patient's best interest), Non-maleficence (doing no harm), Justice (fairness).
• Confidentiality: Maintaining patient information as private, with strict exceptions (e.g., patient or public safety at serious risk, legal requirement).
• Consent: Valid, voluntary, and informed consent is essential for all investigations and treatments. Assess capacity first.
• Capacity: Ability to make a specific decision at a specific time (Mental Capacity Act 2005). Assume capacity unless proven otherwise.
• Duty of Candour: Being open and honest with patients when something goes wrong.
• Professionalism & Integrity: Maintaining high standards of conduct, honesty, and accountability.
• Teamwork & Communication: Effective collaboration and clear, respectful communication with patients, colleagues, and other healthcare professionals.
• Raising Concerns: A professional duty to speak up when patient safety or care is compromised by colleagues or systems.
• Maintaining Boundaries: Professional separation from patients and their families.

Clinical Presentation

• Ethical Dilemmas: End-of-life care, refusal of treatment, capacity assessment, allocation of scarce resources.
• Colleague Conflict: Disagreements with senior or junior staff, concerns about a colleague's competence or conduct (e.g., substance abuse, poor performance).
• Patient Complaints: Handling dissatisfaction, challenging communication, managing difficult family members.
• Errors & Adverse Events: Medication errors, procedural complications, near misses – requiring duty of candour and reporting.
• Breaches of Confidentiality: Accidental disclosure, inappropriate sharing of patient information (including social media).
• Professional Misconduct: Dishonesty, inappropriate relationships, misuse of social media.
• Resource Management: Time pressures, staff shortages, equipment malfunction.
• Consent Issues: Lack of valid consent, patient changing mind, difficulties with communicating information.

Diagnosis (Gold Standard)

The "gold standard" for determining the correct action in a professional dilemma is to **consult the GMC's Good Medical Practice guidance**. This document outlines the standards expected of doctors. Beyond this, a structured approach involves:

• Gathering Information: Ascertaining all relevant facts, perspectives, and potential implications.
• Identifying Stakeholders: Recognising who is affected by the decision (patient, family, colleagues, hospital).
• Applying Ethical Principles: Considering which GMC principles and ethical pillars are most relevant to the situation.
• Reflecting: Considering how your actions align with professional values and potential consequences.
• Seeking Advice: Consulting senior colleagues, your clinical supervisor, MDO (Medical Defence Organisation), ethics committee, or the GMC directly for complex issues.
• Documenting: Recording the dilemma, discussions held, advice sought, and rationale for decisions made.

Management (First Line)

• Prioritise Patient Safety: Always address immediate risks to patient well-being first.
• Communicate Clearly & Respectfully: With patients, families, and colleagues. Be empathetic and professional.
• Escalate Appropriately: Do not try to manage complex or high-risk issues alone. Inform and involve senior colleagues (registrar, consultant, clinical supervisor, nurse in charge).
• Seek Expert Advice: For legal, ethical, or highly sensitive matters, contact your Medical Defence Organisation (MDO) early.
• Document Thoroughly: Record the situation, your actions, discussions with others, advice received, and the rationale for your decisions. This protects you and aids continuity of care.
• Duty of Candour: If an error has occurred, explain it openly and honestly to the patient (or their family, if appropriate), apologise, and outline steps being taken to mitigate harm and prevent recurrence.
• Maintain Confidentiality: Only disclose patient information when legally or ethically justified.
• Challenge Appropriately: If you have concerns about a colleague's conduct or competence, approach them professionally in the first instance. If the concern persists or is serious, follow local policies for raising concerns/whistleblowing, escalating to your clinical supervisor or senior management.
• Reflect & Learn: Use dilemmas as opportunities for personal and professional growth.