How the Professional Dilemmas paper is marked
Last updated 12 October 2026
The Professional Dilemmas paper is not marked right or wrong. Each option you place earns marks by how close it is to the key. Understanding that changes how you should answer, and it is why practising with a right-or-wrong bank teaches you less than it seems to.
The two formats
| Format | What you do | How it is marked |
|---|---|---|
| Ranking | Put four or five actions in order from most to least appropriate | Each option earns up to 4 marks by how close your position is to the key's. Every option is marked, so a five-option item is worth 20 and a four-option item 16 |
| Choose three | Pick the three most appropriate actions from eight | 4 marks for each selection that is in the key, 12 in all. The three are unordered |
The paper has 50 items in 95 minutes, roughly half ranking and half choose-three, spread across three domains: professional integrity, coping with pressure, and empathy and sensitivity. Scenarios are pitched at the level of a Foundation doctor whichever specialty you are applying to. The format, mark totals and the "near-miss" approach are set out in the MSRA Test Blueprint and Information published by NHS England and Work Psychology Group (December 2022).
Ranking: a worked example
The blueprint confirms up to 4 marks per option and a near-miss approach, but NHS England does not publish the marks-by-distance table. MSRA Practice uses the standard inference from those figures: 4 marks for an option in its correct place, 3 for one place out, 2 for two out, 1 for three out and 0 for four out. A perfect order on a five-option item scores 20. Here is a candidate's attempt at an item whose key is A, B, C, D, E:
| Option | Key position | Candidate's position | Distance | Marks |
|---|---|---|---|---|
| A | 1 | 1 | 0 | 4 |
| B | 2 | 3 | 1 | 3 |
| C | 3 | 2 | 1 | 3 |
| D | 4 | 5 | 1 | 3 |
| E | 5 | 4 | 1 | 3 |
| Total | 16 / 20 |
Two pairs of neighbours swapped, and the candidate keeps 80 per cent of the marks. Now the same item answered E, D, C, B, A, the exact reverse:
| Option | Distance | Marks |
|---|---|---|
| A | 4 | 0 |
| B | 2 | 2 |
| C | 0 | 4 |
| D | 2 | 2 |
| E | 4 | 0 |
| Total | 8 / 20 |
Even the worst possible order scores 8, because the middle option cannot move and the second and fourth can only be two places out. The marks that separate candidates are at the ends: the option you put first and the option you put last are the two that can each lose four marks.
What this means for technique
- Find the single best action and the single worst action first. Those two placements carry the most risk. Most candidates can spot the clearly unprofessional option; fewer are reliable about which of two good options is better.
- Then order the middle three. Mistakes here cost one mark at a time. If you are unsure, a plausible middle order loses little.
- Never leave an item unranked. There is no negative marking and an unranked item scores nothing. A guessed order averages well above zero.
- In choose-three, pick three. A fourth is not allowed and two forfeit a third of the marks.
- Judge the options against Good Medical Practice, not against what you would do on a bad day. The key is written to the GMC's standard. Escalating in proportion, being honest with the patient, keeping records accurate and seeking help when out of your depth score; ignoring, concealing and delaying do not.
Why right-or-wrong practice misleads
If a practice bank tells you an item was "wrong" because your order did not match the key exactly, it has thrown away the information you need. Were you four places out on the best option, or did you swap two neighbours in the middle? The first is a gap in judgement; the second is noise. MSRA Practice marks every option by distance, shows you where the marks went, and totals the losses by position and by Good Medical Practice paragraph so you can see the pattern across items rather than one item at a time.
See the marking on real items
Ten scenarios free, marked option by option, no account needed.
Try the free tenSources
- NHS England and Work Psychology Group, MSRA Test Blueprint and Information (December 2022): format, domains, mark totals and the near-miss approach. The marks-by-distance table is not published.
- General Medical Council, Good medical practice (2024), the standard the keys are written to. See Good Medical Practice for the MSRA.
- Format comparison: ranking versus choose three.
Frequently asked questions
Is there negative marking in the Professional Dilemmas paper?
No. The lowest an option can score is zero, so always complete every ranking and always choose three options.
Do I lose all the marks for an item if my order is wrong?
No. Each option is marked separately by how far it is from its correct place. Two neighbouring options swapped lose one mark each; only an option placed four places out scores nothing.
Does the order I pick the three options in matter?
No. In choose-three items the three selections are unordered. Each correct selection earns marks.
Are the exact mark values published?
Only the totals. The NHS England test blueprint confirms up to 4 marks per option, 20 per five-option ranking item, 12 per choose-three item and a near-miss approach, but does not publish the marks-by-distance table. MSRA Practice uses 4, 3, 2, 1, 0 by distance, the standard inference from those figures, and labels it as such.