Aoife Shanahan
Educational Clinical Fellow, Norfolk and Norwich University Hospital

Introduction

Ophthalmology is an exceptionally rewarding specialty, offering an impressive breadth of practice and an ideal balance between clinical and surgical work. From acute presentations in eye casualty to cataract surgery, paediatrics, medical retina, oculoplastics, and more, ophthalmology provides variety alongside an excellent work–life balance.

Competition for ST1 training posts, however, has increased significantly. In 2019, the ratio stood at approximately 3:1; by 2025, this had risen to over 21:1 (1,2). As applicant numbers grow, the Multi-Specialty Recruitment Assessment (MSRA) has become a crucial screening tool for ophthalmic specialty training (OST) applications.

For the 2026 recruitment cycle, the MSRA does not contribute to the final selection score, but it remains an essential first hurdle. Only candidates within the top 300 MSRA scores progress to portfolio scoring and interview. Because the score cut-off fluctuates each year and is not published, performing strongly is the safest way to ensure progression.

This article outlines the structure of the MSRA, recommends useful resources, provides revision strategies and shares exam‑day techniques—based on my own experience achieving a score within the top 1% nationally last year.

Understanding the MSRA

The MSRA is used across many specialties as a standardised method of screening large applicant cohorts. It assesses whether candidates meet a safe baseline standard of clinical knowledge and professional judgement. In the UK, the assessment is delivered as a computer-based assessment in Pearson VUE test centres.

The MSRA is typically 170 minutes in length, however candidates may be allowed 25% or 50% additional time as reasonable adjustments under the Equality Act 2010 (3).

It consists of two independently timed papers. The first paper is on Professional Dilemmas and the second on Clinical Problem Solving (3). There is an optional 5-minute break between the two papers. There is no negative marking.

Professional Dilemmas (PD)

The Professional Dilemmas (PD) paper consists of 50 questions and is typically 95 minutes long, equating to approximately 1 minute and 54 seconds per question. In practice, many candidates aim to spend around 1 minute and 30 seconds per question, allowing roughly 20 minutes at the end to review flagged answers.

The PD paper is a situational judgement test based on the role of an FY2 doctor and presents professional dilemmas within workplace-based scenarios. It assesses three key competencies: professional integrity, coping with pressure, and empathy/sensitivity. The questions do not require knowledge of UK-specific policies or procedures.

There are two types of questions:

• Ranking questions – candidates rank four or five actions in order of appropriateness
• Multiple-choice questions – candidates select the three best answers

Approximately half of the paper consists of ranking questions, with the remaining half made up of multiple-choice questions. PD scenarios are scored using pre-determined keys, and candidates do not need to match the exact order of the key to score highly (4).

Clinical Problem Solving (CPS)

The CPS paper consists of 86 questions and is typically 75 minutes long, equating to approximately 52 seconds per question. Many candidates aim to spend around 40–45 seconds per question initially, which allows 10–15 minutes at the end to review flagged questions.

The exam tests the application of clinical knowledge to everyday clinical scenarios and assesses five main competencies: investigation, diagnosis, emergencies, prescribing, and non-prescribing management. Questions are presented as single best answers (SBAs) and extended matching questions (EMQs) (5).

How to Approach MSRA Revision

Most candidates benefit from at least 6–8 weeks of preparation, although this will vary depending on baseline clinical knowledge. Everyone revises differently, and the guidance below is based on my own experience. You may wish to adapt these suggestions to suit your own revision style and circumstances.

I found that completing a large volume of questions from high-quality question banks was the most effective way to revise, and this also appears to be the most common approach among candidates. However, it is important to revise actively rather than passively. This involves staying focused while doing questions, carefully reviewing explanations, and reading around topics you find more challenging. Your revision strategy should evolve over time as you identify and target weaker areas.

Short, frequent study sessions are generally more effective than long, infrequent ones. Even brief periods of revision can add up quickly. Many people find it helpful to arrive at work early and complete 30–60 minutes of revision in a quiet space before starting their shift. Revising earlier in the day is often easier, as it can be difficult to find the energy to study after a long day at work.

Recommended question banks

PassMedicine

Benefits

• PassMedicine has a very large question bank, with 3396 CPS questions at the time of writing.
• The large size of question bank allows you to practice areas of weakness more thoroughly, as there are large volumes of questions about all topics.
• There is a wide variety of the levels of complexity within the questions. Some are quite complex and niche and others are relatively simple. However, the sheer volume makes it a great resource for extensive practice and for identifying and honing areas of weakness.
• There are two textbooks, a ‘high yield’ textbook and an extended textbook which are both very useful. I generally use the high-yield textbook, but for additional detail the extended textbook can be very helpful.

Drawbacks

• I personally found the quality of the PassMedicine SJT questions to be poor, and I would not recommend using this section of the website. I did not find the SJT questions or answer explanations to be representative of the exam.
• A small number of CPS questions are poorly written. While this did not significantly hinder my revision, it can be frustrating at times.

MCQBank

Benefits

• In my opinion, the questions are generally of higher quality than those on PassMedicine and more closely reflect the style of the real exam.  
• The SJT questions are of excellent quality, with clear explanations and well-reasoned justifications provided for each one.

Drawbacks

• It has a smaller size of question bank, with 1114 CPS questions and 252 SJT questions.
• Some clinical knowledge questions are fairly straightforward and may seem easy, but there is a good mix of question difficulties, including more challenging ones.

I used both question banks together and would highly recommend this approach, as it provides a wide variety of question styles and ensures thorough coverage of the necessary content.

Recommended revision approach

Clinical Problem Solving (CPS) paper

Recommended resources:

• PassMedicine
• MCQBank
• Official MSRA practice paper

Begin your revision with mixed questions across all topics to gain a general overview of the syllabus and identify areas of weakness that need further practice. Once these weaker areas are clear, move on to practising questions by specialty to consolidate knowledge and target gaps more effectively. Focused practice is particularly helpful for topics you repeatedly struggle with, and you should use question-bank textbook explanations and other reliable resources to support this. It is important to be intentional with your revision and avoid working through questions without actively reflecting on your mistakes.

Creating a “common mistakes” document can be very useful. I often wrote out notes from the PassMedicine textbook on points I frequently forgot or got wrong and then revised this document regularly. Writing things out multiple times or making flashcards for commonly forgotten facts—such as medication side effects in diabetes—can also be very effective. Make sure to review this document or your flashcards in the final weeks leading up to the exam.

In the final 2–3 weeks, complete timed mock exams. This helps ensure that you are answering questions quickly enough under exam conditions. Doing mocks without immediately seeing explanations after each question can also be beneficial, as it encourages you to maintain momentum and reflect more carefully on your answers. Do the official MSRA practice paper at least twice close to your exam date to review your knowledge and official question style.

Finally, consider using the “cover test” to avoid distractors. This involves reading the question and thinking of the answer before looking at the multiple-choice options, which can help prevent being misled by incorrect answers or red herrings. While not everyone finds this technique helpful, I found it effective. For questions where you are unsure, use logical reasoning to eliminate options based on what you do know, and then choose the most informed answer.

Professional Dilemmas

Recommended resources:

• MCQBank: most useful
• UKFPO SJT papers
• Official MSRA practice papers
• GMC Good Medical Practice

I would recommend focusing the majority of your PD revision on the MCQBank questions. These are very similar to the actual exam, and I found their explanations particularly helpful. As the exam approaches, make sure to complete the official MSRA PD paper at least once or twice to test your knowledge under realistic conditions. Additionally, UKFPO past papers are available online and, although they are no longer used for foundation programme ranking, they are useful for practising reasoning techniques similar to those required for the PD paper.

Some candidates find it helpful to read through GMC Good Medical Practice to highlight key principles that inform PD reasoning. Personally, I preferred to focus on practice questions, as I found this more effective.

When working through questions, pay close attention to the reasoning behind the correct answer, as this can help guide your approach to future scenarios. Patterns often emerge in how correct answers are structured, and key themes such as patient safety, communication, early escalation, honesty, and teamwork tend to guide most responses.

For ranking questions, it can be easiest to identify the best and worst options first, and then reason through which of the remaining options is more appropriate. If you are unsure between two answers, consider their impact on patient safety—the option that is better for patient safety is usually the correct choice.

I would also advise against starting PD revision too early, as there is a limited bank of MCQBank questions, and revising too far in advance may lead to learning answers by rote.

Exam Tips

• Utilise the Pearson VUE test tutorial before the exam to familiarise yourself with the controls and screen layout in advance of your exam.
• Arrive early and allow plenty of time for the Pearson VUE check-in, as this can often take a while and there is usually a queue.
• Do a few light warm-up questions on the day to get your brain switched on.
• Monitor the on-screen timer and try to stick to your planned timing for each question.
• For uncertain questions, choose your best answer, flag it, and move on—spending too long on one question can cost valuable marks. Return to flagged questions later if needed.
• I personally found the CPS paper to be more time-pressured than the PD paper, so it’s important to keep an eye on the timer throughout.
• Use the earplugs provided. Pearson VUE centres host a variety of exams, so other candidates may be entering or leaving the room during your test, which can be distracting. Earplugs help minimise these interruptions.
• Take the optional five-minute break between papers. Use this time to take a breather, have a drink or snack, and refresh yourself before starting the next section.

Conclusion

Although the MSRA no longer contributes to your overall score, it remains a crucial gateway step. Without a high enough score in the MSRA the rest of your application doesn’t matter.

However, with structured preparation and deliberate practice, it is very passable. Clearing the MSRA confidently allows you to focus on portfolio and interview preparation.

References

1. Health Education England. Competition ratios for the 2025 recruitment round. [Internet]. 2025. [cited 2025 Dec 17]. Available from: https://medical.hee.nhs.uk/medical-training-recruitment/medical-specialty-training/competition-ratios/2025-competition-ratios
2. Health Education England. Competition ratios for the 2019 recruitment round. [Internet]. 2019. [cited 2025 Dec 17]. Available from: https://medical.hee.nhs.uk/medical-training-recruitment/medical-specialty-training/competition-ratios/2019-competition-ratios
3. NHS England. Workforce, training and education. Structure of the Multi-Specialty Recruitment Assessment (MSRA). [Internet]. 2022. [cited 2025 Dec 17]. Available from: https://medical.hee.nhs.uk/medical-training-recruitment/medical-specialty-training/multi-specialty-recruitment-assessment-msra/whats-in-the-msra/structure-of-the-msra
4. NHS England. Workforce, training and education.  Medical Hub. Professional Dilemmas paper. [Internet]. 2023. [cited 2025 Dec 17]. Available from: https://medical.hee.nhs.uk/medical-training-recruitment/medical-specialty-training/multi-specialty-recruitment-assessment-msra/whats-in-the-msra/professional-dilemmas-paper
5. NHS England. Workforce, training and education.  Medical Hub. Clinical Problem Solving Paper. [Internet]. 2024. [cited 2025 Dec 17]. Available from: https://medical.hee.nhs.uk/medical-training-recruitment/medical-specialty-training/multi-specialty-recruitment-assessment-msra/whats-in-the-msra/clinical-problem-solving-paper