Difficult Behaviours

Last updated 1 Jun 2026 · General Practice / Psychiatry

📋 Key Information Summary

📋

Up to 15% of patient encounters in Australian general practice are perceived as "difficult" by clinicians; these consultations consume disproportionate time and emotional energy and are associated with clinician burnout.
"Heartsink" patients are those whose presentation repeatedly evokes frustration, helplessness, or aversion in the clinician — recognise this emotional response as a clinical signal, not a personal failing.
Difficult behaviours exist on a spectrum: from the passive-aggressive or somatising patient, through the demanding/entitled patient, to the overtly angry or threatening patient.
The ABCDE framework (Affect, Behaviour, Content, Diagnosis, Empathy) provides a structured approach to deconstructing challenging encounters and planning management.
Always consider underlying psychiatric diagnoses (depression, anxiety, personality disorders, PTSD, substance use) as drivers of difficult behaviour — behaviour is a symptom.
The angry patient requires a specific consulting strategy: ensure safety first, acknowledge the emotion, use de-escalation techniques, avoid defensive body language, and validate without colluding.
Recognise your own emotional reactions (countertransference) as diagnostic data — irritation, dread before a consultation, or feeling "held hostage" are distress signals in the clinician.
The "Heartsink Survival Kit" includes: setting boundaries, managing expectations, structured follow-up, shared care plans, debriefing with colleagues, and knowing when to terminate the consultation.
Document all encounters involving difficult behaviours objectively; record behavioural observations rather than value judgements (e.g., "patient raised voice and struck desk" not "patient was aggressive").
Clinician safety is paramount — have a clear protocol for escalating to practice security, police (000), or state-based Occupational Violence strategies.
Aboriginal and Torres Strait Islander patients may present with behaviours driven by systemic distrust of healthcare, cultural disconnection, or intergenerational trauma; culturally safe communication is essential.
Regular clinical supervision, peer debriefing, and Balint groups reduce the emotional toll of managing difficult behaviours and are recommended by the RACGP for GP wellbeing.

Introduction & Australian Epidemiology

Managing difficult behaviours and challenging patients is one of the most demanding aspects of Australian general practice. While the doctor–patient relationship is the cornerstone of effective primary care, not all consultations proceed smoothly. A significant minority of encounters involve behaviours that test the clinician's patience, skill, and emotional resilience. Understanding the origins of these behaviours — and developing structured responses — is essential for safe, effective, and sustainable clinical practice.

The term "difficult patient" is widely used but clinically imprecise. More accurately, these are "difficult encounters" or "difficult dynamics" — the challenge arises from the interaction between the patient's needs, presentation style, and the clinician's own emotional response, rather than being an inherent property of the patient alone. Recognising this interactional nature is the first step towards effective management.

Australian Epidemiology

Prevalence: Studies from Australian general practice suggest 10–15% of consultations are perceived as difficult by GPs. The BEACH (Bettering the Evaluation and Care of Health) programme, which ran from 1998–2016, documented that psychological presentations and complex multimorbidity — both associated with challenging encounters — are increasing year-on-year in Australian primary care.
Workforce impact: The RACGP's 2022 General Practice Health of the Nation report identified that difficult patient encounters are among the top contributors to GP burnout and moral distress, alongside workload pressure and administrative burden. Up to 40% of Australian GPs report emotional exhaustion attributable in part to challenging consultations.
Violence and aggression: The AMA and state health departments report that verbal aggression occurs in approximately 5–10% of GP consultations, with physical aggression being rarer but increasing in emergency and after-hours settings. The Victorian Government's Occupational Violence in Healthcare strategy and Queensland Health's Safer Workplace framework provide mandated response protocols.
Patients commonly labelled "difficult": Those with chronic pain (particularly where opioid expectations differ from guideline recommendations), medically unexplained symptoms (MUS), personality disorders, substance use disorders, health anxiety, and those involved in medico-legal or compensation disputes.

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Key principle: The label "difficult patient" reflects the clinician's emotional response, not a diagnosis. Always ask: "What is driving this behaviour?" before concluding that the patient is the problem.

Difficult, Demanding & Angry Patients

Difficult patient behaviours can be categorised into recognisable patterns. Identifying the pattern allows the clinician to deploy targeted strategies rather than reacting emotionally. These categories are not diagnoses — a single patient may display several patterns, and patterns may shift over time.

Common Behavioural Patterns

Pattern	Typical Presentation	Clinician Feeling	Likely Underlying Driver
The Somatiser	Multiple unexplained symptoms, repeated investigations, specialist referrals that yield no diagnosis	Frustration, helplessness, doubt about own competence	Underlying anxiety or depression; distress expressed through the body; past trauma
The Demanding Patient	Insists on specific tests, referrals, or medications; presents long lists; books double appointments without notice; sends frequent emails/messages	Feeling controlled, resentful, rushed	Health anxiety, sense of loss of control, personality traits, previous negative healthcare experience
The Angry Patient	Raised voice, threatening language, slamming objects, refusal to leave, verbal abuse of staff	Fear, defensiveness, anger in return	Pain, grief, feeling unheard, substance intoxication/withdrawal, personality disorder, systemic frustration
The Passive-Aggressive Patient	Agrees to plans in consultation but does not follow through; arrives late; subtly undermines treatment; makes sarcastic or undermining comments	Irritation, confusion, sense of sabotage	Difficulty expressing needs directly; learned helplessness; distrust of authority
The Incessant Talker	Cannot be redirected; ignores time cues; provides excessive irrelevant detail; consultation overruns significantly	Impatience, feeling trapped, falling behind schedule	Social isolation, anxiety, cognitive impairment, loneliness, personality style
The Non-Adherent Patient	Repeatedly fails to attend, does not take medications, does not follow lifestyle advice, presents with complications of non-adherence	Demoralisation, futility, guilt ("Am I failing this patient?")	Health literacy, cultural factors, cost, mental health, ambivalence about treatment, side-effect concerns
The Self-Diagnoser / Expert Patient	Arrives with internet printouts, requests specific diagnoses and treatments, may challenge clinician knowledge	Threatened, dismissed, defensive	Health anxiety, desire for control, previous medical gaslighting, information access without health literacy
The "Heartsink" Patient	The patient whose name on the appointment list provokes a visceral negative reaction — combination of any of the above patterns, often with chronic multimorbidity	Dread, aversion, guilt about feeling aversion	Complex bio-psycho-social presentation; often involves personality pathology, substance use, chronic pain, and social disadvantage

Why Patients Become "Difficult"

Behavioural patterns in the consultation rarely emerge in isolation. Common contributing factors include:

Undiagnosed or undertreated mental illness: Depression, anxiety, PTSD, bipolar disorder, and personality disorders (particularly borderline and narcissistic personality disorder) are over-represented in patients labelled "difficult."
Substance use disorders: Intoxication, withdrawal, and drug-seeking behaviour create predictable patterns of confrontation, especially around opioid and benzodiazepine prescribing.
Chronic pain: Australian guidelines (Faculty of Pain Medicine, ANZCA) acknowledge that chronic pain patients may display challenging behaviour when pain is inadequately managed or when there is a mismatch between patient expectations and guideline-recommended management.
Social determinants of health: Housing instability, financial stress, family violence, and social isolation amplify distress and its expression in the consultation room.
Previous healthcare trauma: Patients who have experienced medical gaslighting, misdiagnosis, or dismissive care may present with guardedness, hostility, or excessive vigilance.
Neurodevelopmental conditions: Autism spectrum disorder and ADHD can present as rigidity, perceived aggression, or difficulty with social cues in the consultation setting.

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Clinical pearl: The most important question is not "How do I manage this difficult patient?" but "What is this patient trying to communicate through their behaviour?" Behaviour is a form of communication, especially when words have failed.

Recognising Distress Signals

Effective management of difficult encounters begins with recognition — both of the patient's distress signals and of the clinician's own emotional responses. Many difficult encounters escalate because early distress cues are missed or dismissed.

Patient Distress Signals

Distress in patients manifests through verbal and non-verbal cues. Learning to recognise these signals early allows proactive intervention before behaviour escalates.

Early / Subtle

Passive Distress Cues

Sighing, avoiding eye contact, fidgeting, repeated checking of phone, short or monosyllabic answers, arms crossed, leaning away, silent crying, asking "Is that it?" at the end of the consultation

Action: Name the observation gently — "You seem a bit unsettled today — is there something else on your mind?"

Moderate / Escalating

Active Distress Cues

Raised voice, rapid speech, interrupting, challenging clinician's qualifications or recommendations, expressing frustration with the system ("Nobody listens to me"), pacing, clenched jaw, tearing up paperwork or prescriptions

Action: Pause the clinical content. Acknowledge the emotion directly. Offer a structured response. Consider safety.

Severe / Crisis

Overt Threat or Aggression

Verbal threats, swearing directed at clinician or staff, standing over the clinician, throwing objects, slamming doors, refusing to leave, physical posturing, direct threats of harm

Action: Prioritise safety. Use duress alarm if available. Do not continue the consultation. Involve practice security. Call 000 if immediate threat.

Clinician Distress Signals (Countertransference)

The clinician's own emotional responses are valuable diagnostic data. Psychodynamic theory calls this "countertransference" — the clinician's feelings in response to the patient. In general practice, these signals are often the first clue that a patient is struggling:

Dread: Feeling of heaviness or anxiety when seeing a patient's name on the appointment list.
Irritation: Disproportionate annoyance at minor behaviours — this often signals that the patient is pushing an unconscious button.
Helplessness: Feeling that "nothing I do helps" — classic in chronic pain, MUS, and personality disorder presentations.
Rescue fantasy: Over-investing in a patient, making exceptions to rules, bending boundaries — may signal counter-dependent dynamics.
Discharge impulse: Wanting to remove the patient from the practice — while sometimes appropriate, if the impulse is sudden and strong, pause and reflect first.
Bodily responses: Tension, fatigue, headache, or somatic discomfort during or after specific consultations — the body often recognises what the mind has not yet processed.

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Reflective practice: After a challenging consultation, take 60 seconds to ask yourself: "What did I feel? What triggered it? What does this tell me about the patient's unspoken needs?" This brief reflection improves subsequent encounters and reduces cumulative emotional burden.

Management Strategies: ABCDE Framework & Heartsink Survival Kit

Structured frameworks help clinicians respond to difficult encounters with intentionality rather than reactivity. Two complementary approaches are widely used in Australian general practice: the ABCDE framework for analysing and managing individual encounters, and the Heartsink Survival Kit for ongoing management of patients who consistently evoke difficult feelings.

The ABCDE Framework

Originally described by Older (1977) and adapted for general practice, the ABCDE framework provides a systematic approach to understanding and managing difficult consultations:

Affect

Identify the emotional atmosphere of the consultation. What feelings are present — in the patient, in yourself? Name them (anger, sadness, fear, frustration). Unnamed affect drives behaviour underground. Acknowledge emotions explicitly: "I can see this is really upsetting for you."

Behaviour

Describe the patient's observable behaviour — not their character. "You raised your voice and stood up" rather than "you were aggressive." Behaviour is modifiable; character labels are not. This also ensures accurate, medicolegally sound documentation.

Content

What is the patient actually saying — and what are they trying to say beneath the surface? The stated complaint ("I need more oxycodone") may differ from the underlying concern ("I'm terrified the pain will never improve"). Listen for the subtext. Use open-ended questions: "Tell me what's really worrying you."

Diagnosis

Formulate a hypothesis about the driver of the behaviour. Is this an undiagnosed depression? A personality disorder? Substance withdrawal? Chronic pain crisis? Grief? Family violence? The diagnostic formulation guides management — you cannot effectively manage a behaviour without understanding its cause.

Empathy & Engagement

Deploy genuine empathy — not just scripted sympathy. Empathy means entering the patient's world and reflecting their experience back to them. "It sounds like you've been suffering for a long time and feel that nobody has taken you seriously." This single statement can transform a hostile encounter into a collaborative one.

The Heartsink Survival Kit

For patients who consistently evoke "heartsink" feelings, a sustained management strategy is required. The Heartsink Survival Kit, drawn from Australian GP education literature, includes the following components:

🔧 For the Clinician

Acceptance of limits: You cannot fix every problem. Accepting this is not failure — it is realistic and sustainable practice.
Regular scheduling: See heartsink patients at predictable intervals (e.g., fortnightly or monthly), at a consistent time, and for a set duration. Containment reduces anxiety for both parties.
Shared care: Involve allied health (psychologist, social worker, physiotherapist, pharmacist) to distribute the emotional load and provide different therapeutic modalities.
Clinical supervision: Peer debriefing, Balint groups, or formal clinical supervision through organisations such as GP Support Program (GPSP) or the Doctors' Health Advisory Service.
Self-care: Prioritise sleep, exercise, boundaries, and personal relationships. A depleted clinician is more likely to react poorly to difficult behaviours.

📋 For the Consultation

Agenda setting: At the start of each consultation, ask: "What are the top three things you want to address today?" Limit the scope proactively.
Written care plan: Develop a GP Management Plan (GPMP, MBS Item 721) and Team Care Arrangement (TCA, MBS Item 723) — these formalise expectations and provide structure.
Boundaries: Define acceptable communication channels (e.g., no direct mobile number, messages via reception only), appointment duration, and expectations around late arrivals.
Positive reframing: Find one thing the patient is doing well. Reinforce it. This shifts the dynamic from perpetual criticism to genuine engagement.
Exit strategy: Have a clear, documented process for transitioning care if the therapeutic relationship has irretrievably broken down — including referral to a colleague, formal discharge letter, and medico-legal documentation.

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Safety-critical principle: If at any point during a consultation you feel physically unsafe, terminate the encounter. You are not obligated to continue a consultation when there is a threat to your safety or that of your staff. Use your practice's duress alarm system, move towards the door, and call 000 if needed. Document the encounter immediately afterwards.

Documentation Standards

Thorough, objective documentation is essential when managing difficult behaviours — both for continuity of care and medicolegal protection:

Record observable behaviours, not subjective judgements (e.g., "patient stood up, pointed finger at clinician, and stated 'you are useless'" — not "patient was abusive").
Document any safety concerns and actions taken (e.g., "duress alarm activated; reception staff moved to back office; patient asked to leave; police called at [time]").
Include your own clinical reasoning about the behaviour: "Behaviour consistent with acute intoxication; patient appeared to be under the influence of methamphetamine based on dilated pupils, diaphoresis, and pressured speech."
Add a behavioural flag in the patient's record (using your clinical software's alert function) to ensure future clinicians are prepared, while avoiding stigmatising language.

The Angry Patient: Consulting Strategies

Anger in the consultation requires specific strategies because it activates the clinician's own threat response (fight-flight-freeze), which impairs clinical reasoning and empathy. A structured approach allows the clinician to de-escalate while maintaining professional boundaries.

Pre-Consultation Preparation

Review the record: Before entering the room, check the patient's file for previous behavioural flags, recent crises, medication changes, and outstanding investigations.
Check the environment: Ensure you are seated closest to the door (do not let the patient sit between you and the exit). Remove potential projectiles (scissors, heavy objects) from easy reach. Ensure your duress alarm is functional.
Emotional preparation: Take three slow breaths. Remind yourself: "This person is in distress. My job is to understand, not to win."

The De-Escalation Sequence (CALMER)

Calm Yourself First

Regulate your own breathing and body language. Slow your speech. Adopt an open posture — uncrossed arms, relaxed hands, slightly leaned forward. Avoid mirroring the patient's agitation.

Acknowledge the Emotion

Name what you see: "I can see you're really angry/frustrated/upset." This is the single most powerful de-escalation tool — it validates the patient's experience without agreeing with their behaviour. Avoid saying "Calm down" — this invariably escalates.

Listen Actively

Let the patient express their grievance fully without interruption (within safety limits). Use reflective listening: "So what you're telling me is…" Paraphrase accurately. This demonstrates respect and gathers diagnostic information.

Manage the Problem

Once the emotion has been acknowledged, transition to problem-solving: "Now that I understand what's happened, let's work out what we can do." Offer realistic options. Avoid making promises you cannot keep.

Establish Boundaries

If anger persists or becomes abusive, set clear limits: "I want to help you, but I cannot continue this conversation if you're swearing at me. Can we agree to speak respectfully so I can focus on your care?" If boundaries are not respected, state the consequence and follow through.

Resolve or Refer

Aim for a concrete next step by the end of the encounter: a prescription, a referral, a follow-up appointment, a safety plan. If you cannot resolve the issue, acknowledge this honestly and offer an alternative pathway.

What NOT to Do

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Do not say "Calm down" — this invalidates the patient's emotional experience and almost always escalates anger.
Do not match their intensity — raising your voice or adopting aggressive body language increases the risk of violence.
Do not take it personally — anger is almost always about the patient's situation, not about you as an individual.
Do not make threats you won't carry out — if you say "I will call security," you must be prepared to do so. Empty threats destroy credibility.
Do not provide opioids, benzodiazepines, or sick certificates solely to end an angry encounter — this reinforces the behaviour and creates medicolegal risk.
Do not document emotionally — write "patient stated 'I will make you pay'" rather than "patient threatened me viciously."

After the Encounter

Debrief: Speak with a colleague, practice manager, or call the Doctors' Health Advisory Service (DHAS — available in all states and territories) within the hour if the encounter was threatening or distressing.
Document immediately: Contemporaneous notes carry the most weight medicolegally. Record facts, not interpretations.
Review practice protocols: If the incident exposed gaps in safety procedures (e.g., duress alarm not working, staff unaware of protocol), address these before the next patient arrives.
Consider formal management plans: For repeated incidents, develop a documented behavioural management plan in collaboration with the practice, and consider whether ongoing care in your practice is appropriate.

Special Populations

Certain patient populations require tailored approaches when presenting with difficult behaviours, due to specific vulnerabilities, communication needs, or systemic factors.

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Children & Adolescents

Anger and oppositional behaviour in young people often signals bullying, family violence, neurodevelopmental conditions (ADHD, ASD), or emerging mental illness.

Assess separately from parents when possible (private conversation from age ~12 years).

Use age-appropriate language; avoid pathologising normal developmental behaviour.

Refer to headspace, CAMHS (Child and Adolescent Mental Health Service), or school counsellor as appropriate.

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Elderly Patients

New-onset difficult behaviour in an elderly patient — always consider delirium, dementia (particularly frontotemporal), medication adverse effects (anticholinergics, corticosteroids), pain, and urinary retention.

Undertreated depression in the elderly may present as irritability and demanding behaviour rather than sadness.

Screen for elder abuse — behavioural changes may be a signal of abuse by a carer.

Use the KICA (Koori Cognitive Assessment Tool) or MMSE/MoCA for cognitive screening when indicated.

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Pregnant & Postnatal Women

Anger and irritability in the perinatal period may represent perinatal depression, anxiety, or PTSD (including birth-related trauma).

Screen with the Edinburgh Postnatal Depression Scale (EPDS) — note that irritability and anger are core features, not just sadness.

Ask routinely about family violence using a validated tool (e.g., WAST — Woman Abuse Screening Tool).

Refer to perinatal mental health services, PANDA (Perinatal Anxiety & Depression Australia — 1300 726 306), or Tresillian/Karitane for parenting support.

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Patients with Renal Impairment

Uraemia causes cognitive impairment, irritability, and personality change — always check eGFR and electrolytes in patients on dialysis presenting with new behavioural disturbance.

Patients on dialysis face significant quality-of-life burden; anger and frustration may be an appropriate response to their circumstances.

Coordinate with the renal team; consider psychiatric referral if behaviour persists after optimising dialysis and metabolic parameters.

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Patients with Substance Use Disorders

Intoxication and withdrawal are among the most common causes of acute angry behaviour in healthcare settings. Assess for intoxication (alcohol, methamphetamine, opioids, benzodiazepines) systematically.

Maintain non-judgemental stance. Separate the behaviour from the person. Provide clear boundaries around prescribing.

For opioid-dependent patients: ensure access to Opioid Substitution Therapy (OST) through the state-based pharmacotherapy programme. Do not abruptly cease long-term opioids without a tapering plan.

Alcohol and Drug Information Service (ADIS) — available in all states/territories. For acute intoxication risk, consider Naloxone (Nyxoid® nasal spray) if opioid overdose suspected.

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Patients with Intellectual Disability or ASD

Behavioural escalation may reflect sensory overload, communication frustration, pain that cannot be articulated, or changes to routine.

Use visual supports, simple language, and allow extra time. Consult the patient's carer or support coordinator.

Refer to the NDIS Behaviour Support Practitioner if restrictive practices are being considered.

Contact the Intellectual Disability Behaviour Consultation (IDBC) service in your state for specialist advice.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Cultural Safety

Difficult behaviours in Aboriginal and Torres Strait Islander patients must be understood within the context of colonisation, intergenerational trauma, the Stolen Generations, and ongoing systemic racism in healthcare. What appears as anger or non-adherence may be a rational response to a healthcare system that has historically caused harm. Clinicians must practise cultural humility — recognising that the patient is the expert on their own experience and that Western frameworks of "difficult behaviour" may not map neatly onto Indigenous ways of being.

Communication Styles

Direct questioning and confrontation are often culturally inappropriate in many Aboriginal and Torres Strait Islander communities. "Shame" is a powerful concept — being made to feel shame in a consultation can result in withdrawal, anger, or disengagement. Use yarning-based approaches: allow time, listen without interrupting, use indirect questioning, and build relationship before addressing clinical content. The RACGP's Specific Interests: Aboriginal and Torres Strait Islander Health network provides guidance and training.

Systemic Barriers

Anger directed at healthcare staff may reflect frustration with systemic failures: long wait times, culturally inappropriate services, lack of Aboriginal Health Workers (AHWs), housing instability, food insecurity, and the cumulative effect of navigating a system not designed for Indigenous Australians. Recognise when the anger is about the system, not about you. Advocate within your capacity.

Social and Emotional Wellbeing (SEWB)

The SEWB framework recognises that wellbeing for Aboriginal and Torres Strait Islander peoples encompasses connection to land, culture, spirituality, ancestry, community, and family — not just the absence of mental illness. Disruption to any of these connections (e.g., through displacement, loss of language, family breakdown) can manifest as distress, anger, or substance use. Assess SEWB holistically using frameworks endorsed by the Australian Indigenous Doctors' Association (AIDA).

Referral Pathways

Engage Aboriginal Health Workers and Aboriginal Liaison Officers (ALOs) early in managing challenging encounters. AHWs can provide cultural brokerage, facilitate communication, and advocate for the patient within the healthcare system. Referral to Aboriginal Community Controlled Health Organisations (ACCHOs) such as AMS (Aboriginal Medical Services) may provide a more culturally safe environment. Yarn Safe (headspace's Aboriginal and Torres Strait Islander programme) and Beyond Blue's Yarning about Mental Health resources are available.

Family Violence

Aboriginal and Torres Strait Islander women experience family violence at significantly higher rates than non-Indigenous women (AIHW, 2023). Difficult or angry presentations in Aboriginal women should always include a private, culturally sensitive enquiry about safety at home. 1800RESPECT (1800 737 732) and Djirra (Victoria — 1800 105 303) provide specialist support.

📚 References

1. Royal Australian College of General Practitioners (RACGP). General Practice: Health of the Nation 2022. Melbourne: RACGP; 2022. Available from: www.racgp.org.au
2. Older J. The art of psychotherapy in the general hospital. British Journal of Psychiatry. 1977;130:564–571.
3. Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor-patient relationship: somatization, personality and psychopathology. Journal of Clinical Epidemiology. 1994;47(6):647–657.
4. Coulehan JL. The "difficult" patient: an ethical perspective. Journal of General Internal Medicine. 1990;5(6):530–534.
5. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary Report 2023. Canberra: AIHW; 2023.
6. Groves JE. Taking care of the hateful patient. New England Journal of Medicine. 1978;298(16):883–887.
7. Royal Australian College of General Practitioners (RACGP). Specific Interests: Aboriginal and Torres Strait Islander Health — Cultural Safety Training Framework. Melbourne: RACGP; 2021.
8. Victorian Government Department of Health. Occupational Violence in Healthcare: A Practical Guide for Managing Code Grey and Code Black. Melbourne: Victorian Government; 2022.
9. Drossman DA. Abuse, trauma, and GI illness: is there a link? American Journal of Gastroenterology. 2011;106(1):14–25.
10. Balint M. The Doctor, His Patient and the Illness. 2nd ed. London: Churchill Livingstone; 1964.
11. Australian Indigenous Doctors' Association (AIDA). An Introduction to the Social and Emotional Wellbeing Framework. Canberra: AIDA; 2020.
12. Jackson-Bowers E, Holmwood J. General Practice Management of the "Difficult" Consultation. Adelaide: Primary Mental Health Care Australian Resource Centre (PMHARC); 2003.
13. Harris I, Gavel P. Doctors' wellbeing — why and how? Medical Journal of Australia. 2010;192(8):470–472.
14. National Mental Health Commission (NMHC). The National Review of Mental Health Programmes and Services. Sydney: NMHC; 2014.
15. Australian Medical Association (AMA). AMA Position Statement: Safety of Doctors and Medical Students — 2022. Canberra: AMA; 2022.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).