Understanding "Appropriateness" Questions

Appropriateness questions form the backbone of the SJT. You are presented with a scenario and a series of possible actions. For each action independently, you must rate it on a four-point scale. This lesson provides a deep understanding of what each rating truly means, how to distinguish between adjacent ratings, and the concept of "ideal" versus "not ideal but acceptable."

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The Four-Point Scale

Rating	Shorthand	What it means
A very appropriate thing to do	VA	This is what a competent, ethical professional should do. It directly and fully addresses the core issue
Appropriate, but not ideal	A	This action has merit and is acceptable, but it either does not fully address the issue, misses an element, or is not the primary response
Inappropriate, but not awful	I	This action is not recommended. It fails to address the issue, is disproportionate, or demonstrates poor judgement — but it does not cause direct harm
A very inappropriate thing to do	VI	This action is clearly wrong. It is unethical, dangerous, dishonest, or could cause significant harm

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What Makes Something "Very Appropriate"?

An action rated VA must meet all of the following criteria:

Criterion	Explanation
Directly addresses the core issue	It tackles the primary problem, not a secondary concern
Is ethically sound	It aligns with the four pillars of medical ethics
Is professionally correct	It follows GMC and NHS guidelines
Is proportionate	It matches the severity of the situation — neither too much nor too little
Demonstrates NHS values	It reflects compassion, respect, teamwork, quality, or equity

Examples of "Very Appropriate" Actions

• Raising a patient safety concern with the appropriate person
• Ensuring a patient understands their treatment before consent
• Speaking privately to a colleague about unprofessional behaviour
• Admitting a mistake and taking steps to address it
• Seeking help when a task is beyond your competence

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What Makes Something "Appropriate, but Not Ideal"?

This is the rating that causes the most confusion. An action rated A is not wrong — it is acceptable — but it has a limitation.

The Five Reasons an Action May Be "Appropriate, but Not Ideal"

Reason	Example
1. It addresses the issue but not optimally	Mentioning a concern to a colleague in passing rather than having a proper conversation
2. It is a secondary action, not the primary response	Reporting a minor issue to management when a direct conversation would be more appropriate first
3. It misses one element of the ideal response	Correcting an error but not reporting it through the incident system
4. The timing or method is suboptimal	Raising a valid concern publicly rather than privately
5. It solves the problem for now but not long-term	Covering a colleague's shift without addressing why they are consistently absent

The Key Distinction: VA vs A

Very appropriate = the primary, direct, complete response to the core issue Appropriate, but not ideal = a reasonable, acceptable response that has a limitation

Worked Example

Scenario: A fellow student tells you they fabricated a patient encounter for their portfolio.

Action	Rating	Why
Urge them to self-report to their tutor, and explain the seriousness of fabrication	VA	Directly addresses the core issue; gives the friend the first opportunity to act honestly
Report the fabrication to the medical school immediately	A	Correct to report, but a direct conversation first is the ideal approach
Say nothing because it is their business	VI	Fails to uphold academic integrity; could lead to a dishonest doctor
Tell other students about it but do not report it formally	I	Gossip does not address the issue and is unprofessional

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What Makes Something "Inappropriate, but Not Awful"?

An action rated I is not recommended but does not cross the line into being clearly harmful or dangerous.

Characteristics of "Inappropriate, but Not Awful"

Characteristic	Example
Inaction when action is needed	Doing nothing when a colleague is struggling
Disproportionate response	Reporting a single late arrival to the GMC
Poor judgement, not malice	Discussing a workplace issue with friends outside the profession
Fails to address the issue	Acknowledging a problem but hoping it resolves itself
Correct intention, wrong method	Confronting someone aggressively about a genuine concern

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What Makes Something "Very Inappropriate"?

An action rated VI is clearly wrong and no reasonable professional would consider it acceptable.

Characteristics of "Very Inappropriate"

Characteristic	Example
Puts patients at risk	Ignoring a medication error
Is dishonest	Covering up a mistake
Violates core principles	Breaching confidentiality without justification
Is discriminatory	Treating a patient differently based on a protected characteristic
Enables harm	Covering for an impaired colleague
Demonstrates contempt	Mocking a patient or colleague

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Rating Each Action Independently

This is a critical concept that many candidates miss.

You are NOT ranking the actions against each other. You are rating each action on its own merits.

What This Means in Practice

Correct approach	Incorrect approach
Action A could be VA and Action B could also be VA	"One of these must be higher than the other"
Action C could be I and Action D could also be I	"I need to make these different ratings"
Two actions can have the same rating	"Each action needs a unique rating"

Why This Matters

If you mistakenly try to rank actions (giving each a unique rating), you will force incorrect ratings. A scenario with three good options might have three VA ratings. A scenario with two bad options might have two VI ratings.

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The Partial Credit Safety Net

Remember that SJT uses partial credit scoring:

Your answer vs correct answer	Marks
Exact match	4 marks
One step away	3 marks
Two steps away	2 marks
Three steps away (maximum error)	0 marks

Strategic Implications

Situation	Strategy
You are torn between VA and A	Choose either — you will score at least 3 marks regardless
You are torn between A and I	Choose either — you will score at least 3 marks regardless
You are torn between VA and I	This is a bigger gap — try to resolve it; but even being one step off the correct answer scores 3 marks
You have no idea	Choose a moderate answer (A or I). These are at most one step from any adjacent rating, giving you a guaranteed minimum of 3 marks in many cases

The golden rule: When genuinely uncertain, moderate answers (A or I) are statistically safer than extreme answers (VA or VI), because they minimise the maximum possible error.

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The Quick-Decision Framework for Exam Conditions

When you have ~23 seconds per question, use this rapid framework:

Step 1: Patient Safety Check (3 seconds)

• Does this action protect patient safety? → Lean towards VA
• Does this action risk patient safety? → Lean towards VI
• Is patient safety not directly involved? → Move to Step 2

Step 2: Professional Standards Check (3 seconds)

• Would the GMC approve this action? → Lean towards VA or A
• Would the GMC disapprove? → Lean towards I or VI

Step 3: Degree Check (3 seconds)

• Is this the primary, direct response? → VA
• Is this reasonable but not the primary response? → A
• Does this fail to address the issue? → I
• Is this actively harmful or dishonest? → VI

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Key Takeaways

• The four-point scale runs from "very appropriate" (ethically correct, direct, proportionate) to "very inappropriate" (harmful, dishonest, dangerous)
• "Appropriate, but not ideal" means the action is acceptable but has a limitation — it is not wrong, just not the best
• Rate each action independently — do not force unique ratings across actions
• Partial credit scoring means that being one step off still earns 3 out of 4 marks
• When uncertain, moderate answers (A or I) are statistically safer than extreme answers
• Use the three-step rapid framework: patient safety → professional standards → degree of response