As the exodus of doctors and nurses from Croatia to the rest of the EU becomes more and more evident, people have even begun to fight to work without proper UK qualifications. I am currently sitting at work listening to the nurses in Dvor talking about moving and the logistics of working in the UK. These people cannot speak a word of English and are already planning their move to the UK.

A little bit of background story. I grew up mostly in the US, but am not an American citizen. My father was a diplomat and our family started off in McLean, VA when it was a poorer neighborhood of DC. All my childhood friends are from the US and I my mother tongue is English as my parents didn’t really use Malay as a family language. I was never connected to Malaysia and if you asked me to name any of my cousins, I don’t know their names (as they were referred to by nick names). I graduated from NC State University with my Bachelor’s in Biochemistry and after two years, went to University of Zagreb (previously Harvard Medical International) for medical school. I graduated in 2009, passed the Croatian State Exam and got licensed with the Croatian Medical Chamber. I started working on the coast and currently hold a position in the Department of Emergency Medicine Sisak-Moslavina County.

I wanted to specialize in the UK to do my specialization in my mother language. After working in Croatia for years, I would like to live somewhere a bit more normal. All around me, I have seen my colleagues move up north to a better education, better facilities and a more stable life. So I decided to ask the General Medical Council UK and Irish Medical Council about the procedures in which to proceed. Looking only at my nationality, they told me I need to sit for the PLAB or licensing exam again AND take an English language test.

The Croatians have the same qualifications as I do, and having a Bachelor’s Degree in Biochemistry, I’m actually more qualified and have more experience in more facets of medicine.

Dear Sir or Ma’am,

I am confused by the website, because it doesn’t have the information held or it seems unfair for a person in my position. I am a Malaysian citizen who has been living in Croatia for the past 13 years. As a quick background story, my parents were diplomats and I grew up in the USA. Either way, I hope you can see that my English is proficient enough and currently I have to practice medicine in Croatian, which is very difficult.

So I would like to continue my career in the UK. There are a few factors I need answered / addressed. As you know since Croatia joined the EU, there has been a steady flow of Croatian doctors to the EU and some of my colleagues / friends have left and have not needed to pass the PLAB or IELTS. However, I have been told that I need to pass both just based on my nationality and not my qualifications.

I graduated from the University of Zagreb Faculty of Medicine (EU school) as a medical doctor and from North Carolina State University (USA) as a biochemist (pre-med). I hope that I can get information on the bureaucracy of the GMC. I also do not understand the registration to GMC and then the extra fees for registration as a specific type of doctor (GP or specialist).

If I just register to the GMC, does that not mean I’m licensed or is that paying 400 GBP for having my name on a list? Do I still have to pay the 1600 GBP registration fees as a GP, which I assume is a general practitioner?

Thank you for your time in answering my questions.


Dr. Azman


Dear Dr Azman

Thank you for your email about applying for registration.

If a doctor has a European nationality then they have freedom of movement being a member of the European Economic Area (EEA) which is why some of your colleagues who are Croatian don’t need to do the Professional and Linguistic Assessment Board (PLAB) test. However, as your nationality is Malaysian then you are classed as an International Medical Graduate (IMG) and there are four routes to registration:

a. a pass in the PLAB test
b. sponsorship by a GMC approved sponsor
c. possession of an acceptable postgraduate qualification
d. eligibility for entry onto the Specialist or GP Registers.
The annual retention fee for a registered and licensed doctor is £425 per year. The £1600 is an application fee to get onto either the GP or Specialist Register. Once on there then the annual retention fee is the same (currently £425).

If you want to work as a General Practitioner (GP) in the UK then you need to be on the GP register. The application is known as a CEGPR (Certificate of Eligibility onto the GP Register). You would need to read the following specialty specific guidance:

If you would like to discuss this further then please ring our Contact Centre (telephone: 0161 923 6602 (+44 161 923 6602 from outside the UK) who will be happy to help you. We are open Monday to Friday 08:00-18:00 and Saturday 09:00-18:00. Alternatively. please reply to my email.

Yours sincerely


Ann Swire
Contact Centre Adviser
Registration and Revalidation Directorate
Telephone: 0161 923 6602 (+44 161 923 6602 from outside the UK)

It is pure discrimination. I have contacted the EU Ombudsman, but need legal advice to see if I have a case. Since I moved to the EU, I have seen more discrimination, more racism, more segregation of cultures than in North Carolina, one of the southern states.



“The total number of licensed doctors in Croatia is about 18000 and according to the data from NHII in April 2012 there were 2340 GP/FPs. 47% of them are specialists, and only 23% are men. Most of the GPs/FPs , 85%, work as self-employees with contracts to NIHI (official data from Croatian Medical Chamber, 11.01.2012). 15% of GPs/FPs work as public employees at Medical Health Centers.” –

That is 1 primary care physician per 500 people approximately. UK has about 1:400.  South Africa has 1:1500. The problem is distribution of PCP. So basically, people are also leaving after joining the EU.

My question is: Where did all the doctors go? Think about it. Every country is in deficit as long as I read. Is there one island in the pacific where there is like 1 doctor for every 10 people? Are Saudi countries stealing all of them with money?

I asked the recruiter for the UK one day and he said that UK/Irish doctors are leaving to Australia for better weather. That is understandable. Then I read that Madagascar has only 5 mobile units. That is to cover the ENTIRE country.

The USA is not lacking doctors, but has more specialists than primary care physicians than any country. People live the American dream, work, specialize and then earn more money. However, there is always a lack.

So where do all the doctors go?

And why am I not there?

I really hope it’s Hawai’i.

Why is getting kicked in the balls worse than pregnancy pain?  After a few years, you don’t hear guys saying, “Well, I wouldn’t mind getting kicked in the balls again…”

Pain is one of the most difficult “symptom” to deal with in medicine.  I didn’t really believe the range of pain until I started working in the field and seeing people’s different responses to pain; from kids writhing in pain even before I touch them to a man not even flinching when I debrided his wound.  There are many examples in between where people range from yelling to a simple ow (in Croatian this is translated into “ajoj”).  So for a medical doctor, the extent of diagnostics depends heavily on “guessing” how the patient’s pain translates into symptom or a real diagnosis.

For me, life can’t be without pain.  For example, people feel angina pectoris from a stressful breakup to actually having dying cells from myocardial ischemia (heart attacks).  So I am constantly in “some kind of pain”.  So why do people feel pain differently?  Nobody knows.  There are many types of pain ranging from somatic, visceral, psychosomatic and central.  Putting aside all of the medical terminology, these are pain that you feel depending on location.  If you cut yourself, for instance, you will feel a sharp type of pain.  However if you notice, your pain will dull with time, despite the cut being there.  Itching for some is sometimes painful for others.  So the diagnosis of pain is a difficult one and as a doctor, we are trained to use the worst diagnostic tool (besides the Bristol Stool Chart) to gauge the value of pain that the person experiences.

Pain, being the main symptom of most patients, is then a very confusing symptom to deal with.  What is important for us to know are the details of pain and that is done through SOCRATES (I am sure your doctor has asked you at least some of these questions to narrow down his or her differential diagnosis).  SOCRATES stands for: Site, Onset, Character, Radiation, Associations, Timing, Exacerbating factors, and Severity.  Some pain symptoms, no matter the severity, is pathognomonic for certain diseases (i.e., RUQ pain radiating to back is indicative of acute pancreatitis).  There’s a cheat sheet.  Don’t think we’re all clever.

However due to the controversy on the news about opioids (a type of pain medication) being over-prescribed for CHRONIC pain management, I would like to talk about that here.  So what is chronic pain?  What are the different types of pain medication and what do they do?  How do you deal with that pain?  These are all hard questions and pain research, like most medical research, is relatively young.  However since pain is subjective, it is ethically hard to figure out how to research what pain really is.  For instance, a woman giving birth and tearing her vaginal canal would rate a bad smiley face, whereas a yuppie who had a silver-spoon life would cry at a papercut (NOT stereotyping, patients I’ve had).  Even if you try to measure biochemical reactions of pain neurotransmitters while unethically inflicting pain on your subjects…

…you would get zig-zag, scatter-type graphs, despite trying to compensate for genetics, culture, gender, age, etc.  Therefore, pain is a VERY open field and is still trying to be understood.

So What Is Chronic Pain?


Meh.  That is like asking again, “What is pain?”  Chronic pain is some sort of, usually and hopefully, dull pain that effects a certain region of your body or even sometimes your entire body.  The latter is harder to figure out, but usually goes away with massages and feel-good activities.  However, most of these patients are in the older population, usually have had some sort of injury or surgery, and are prescribed opioids to manage their pain.  Yes, that might seem like the lazy thing to do, but a doctor cannot manage a person’s life as much as they would like to.  On top of that, people really don’t like following advice until they get scared with death (one of the side-effects of opioids).

That said, and in my field of rural emergency, I encounter many patients who are chronically on opioids and arrive on the field because of diffuse chronic pain.  It’s a frustrating aspect of my job, where the only thing I can do is alleviate the acute symptomatic flare with more painkillers.  I won’t go into the details of why someone might have chronic pain, but it is usually mismanaged.  So how do we stop this?  First we have to understand how we prevent pain, and before we do that, we have to understand the source of the pain in the first place.  So basically secondly, we have to understand how we can prevent pain.  Firstly…never mind.

So yes, pain.  SOCRATES.  With SOCRATES, you can PROBABLY figure out why the patient is in chronic pain.  What does chronic pain mean to you?  Does that mean that you’re immobile?  Can you do normal functions at home?  If you are hindered due to painful events, it does make life difficult and can cause stressful situations at home and at work.  That annoying pain that you’ve had due to twisting your knee when you were 21 can suddenly become debilitating when you’re 35.  Does that mean you’re unhealthy and need some sort of medical intervention?  All these questions related to pain, I find, are related to the most important, and most forgotten, part of modern medicine; which is QUALITY OF LIFE.

If you can’t maintain your quality of life, then you are basically not fulfilling the WHO definition of health (physical, mental and social health).  When this happens, it causes stress within yourself and your surrounding community.  So how do most people alleviate that?  Through taking prescription pills.  Remember how doctors have thousands of patients and will say?

“Take this for a few weeks, please exercise [insert part of body here] and follow healthy habits and come back for a checkup.”

Most people don’t live a healthy life, which could exacerbate pain (sedentary lifestyles make some chronic pain worse).  Some people have to get back to work and physically do repetitive movements, which is the cause of the pain in the first place (please lift with your legs!).  Like I said, most doctors don’t have time to mediate lifestyles, so this is up to the population to understand and compensate.  If I were a mechanic, I can fix your brakes and tell you not to brake so suddenly and plan your driving route.  However, you probably would go back to habit and drive like a maniac.

If you don’t want to be stuck on opioids, lifestyle changes are the key to chronic pain management.  Since every case is different and every person has their own subjective opinions on pain, it is hard to say what the best course of action is.  However, if you want your quality of life back and realize that even opioids are not working for you, then it is time to try different variations of pain management which does not require addictive medication.

The Good Stuff?

In a few quick paragraphs, I would like to go into a few common painkillers, and quickly describe what they are good for.  You can research these online to see what works for different occasions, but everyone reacts differently to pain medication because nobody knows where their pain is coming from.  So to understand the type of pain, you have to understand what alleviates it.


Aspirin is described as a near-perfect drug.  Being used for a LONG time in its “alternative medicine” form as a hot drink to relieve fevers, the base of aspirin is (you can just Wikipedia this instead of me writing out a synopsis) an anti-inflammatory and also a COX inhibitor.  Long story short, this type of inhibition blocks the interleukins (biochemical messengers) that cause pain and fevers.  Besides being bad for your stomach by not blocking acidity production and protection thus causing ulcers, there are not many other side-effects (super fever by taking too much).  This universal painkiller is good for headaches, muscular cramping and joint pain.


Another commonly used pain killer is APAP (paracetamol, Panadol, Tylenol or acetaminophen).  Found through a fluke, APAP is amazing at cutting off pain and is still poorly understood.  It has a COX2 inhibiting property, which makes it act like aspirin in a more specific way and reduces fever, but it is also somewhat bad for your liver (do not take with alcohol!), since it is metabolized in it.  There is also a mechanism where it blocks pain transduction in the spine itself, so it is very good for peripheral pain symptoms that are not due to inflammatory effects (sprained ankles and such).  This painkiller is combined with other potent painkillers to create combinations for “hard or heavy” pain, which is taken chronically and can cause potential liver problems later in the future.  I would use APAP for fevers and not chronically, although it does help.

Ibuprofen and Other NSAIDs

NSAID stands for Non-Steroidal Anti-Inflammatory Drugs.  From the name and a little bit of logical medical knowledge, you can derive what it does.  There are MANY drugs in this category and they all do the same thing to different levels of relief.  Since they are an anti-inflammatory, they can reduce immune reactions in your body, creating a range of relief from the inflammatory reactions that cause arthritis to the inflammatory reactions that cause fevers.  In that sense, they are good when your joints are inflamed when you twist them or injure them in any way.  Since they work on different places of pain management, I like to alternate NSAIDs and APAPs daily to effectively reduce ACUTE symptomatic pain.


Opioids are AWESOME!  Despite being the derivatives of heroin, modern biochemistry and chemistry have honed their art to making key-lock mechanisms for the super-addictive nature of the natural painkiller (eat that, you f-ing hippies!), opium.  Basically working on natural opioid receptors, these natural painkillers will block almost most types of pain.  Unfortunately, they are still very addictive and if used chronically, they will cause upregulation of the receptors and you will need a larger dose to get the same level of relief.  Most chronic pain patients are treated with opioids and thus the controversy in modern medicine.  Although prescribed to alleviate pain during physiotherapy, most patients will subconsciously feel pain after and discontinue their physiotherapy in lieu of a quicker pain fix (Dr. House?).

The Chronic!

When I was training for triathlons, people would tell me to get high so that I could lift weights better.  I wasn’t a smoker so it really irritated me, but I could tell you that it worked.  I could hardly feel pain for the few hours that I was high, but that comes with any downer high (like opioids).  Since medical marijuana became a “thing”, many chronic pain patients are on the chronic (and many more who are not in pain).  However, the Mary has always decreased the amount of productivity in the working class, so I will not talk about this further due to a lot of conflict from recreational users advocating the “goodness” of a “natural” drug that has mental side effects, who could easily be sipping willow bark tea (aspirin) to lower their pain levels.

The Alternative?  Better Than Drugs!

So why don’t we just alternate drugs and treat CHRONIC pain through mixing pills?  Well, it’s complicated.  If I wasn’t there to regulate, would you really comply?  Honestly, would you?  And the second is that chronic pain is different.  Once you start taking pills for years, your body will eventually get used to the pills (will NOT explain upregulation, Google it).  So is there a better way?  You bet there is!  So what is the alternative, you ask?

You won’t like it, but the healthier option is (obviously) a healthy lifestyle.  That might be a vague concept, but chronic pain disappears when you are in a state of less stress.  Imagine chronic muscle pain and then getting a massage.  Imagine your boo-boo when you scrape your knee and your mother blows on it.  Imagine your back pain when you are having amazing sex.  Yes.  All these things block pain receptors in much the same way that pharmaceuticals block them and if you want to know the biochemistry and physiology behind it, feel free to use Google (I don’t get paid enough to type out answers, but if you want to know over beer, feel free to contact me).   So reading through all the chronic pain management articles on the inter-web from variable sources, I based it to TRAIN (nooooooo!).


Yes.  You have to exercise.  You have to regulate your body to stretch your muscles and increase circulation.  Most people will feel pain in the beginning and it will be overbearing, but after a few weeks, your body will compensate and down-regulate those pain receptors and you be able to manage the symptom of pain.


The body needs to regulate itself and most people are in the constant state of bad stress.  When you don’t get enough bed rest, your body will always be in the state of shock and stress causes pain (again with the biochemistry).  Meditating on the pain can also alleviate the pain and, done properly, it can also relax the part of the body disturbing you.


Besides stopping smoking and drinking (which most patients won’t do), antioxidants will combat these toxins that you are putting in your body every day.  If you follow any type of nutrition website, anything can be an antioxidant, but try to include potent antioxidants.  By creating a protective barrier against oxidizing stress on your body, you can better alleviate symptoms due to (well…) smoking and drinking.


This might be the most important aspect of medicine that people seem to forget.  Trust your doctors, but always question their decisions.  Be well informed on how to increase your quality of life and the more you share with your primary physician, the more they are informed on how to manage your lifestyle so that you can further improve your condition and not rely on heavy medication to alleviate your pain.


“Just say no!” was the 1990s anti-drug campaign I grew up with.  These medications are made to alleviate pain while you recover and not to keep you in a constant state of addiction.  During that CNN interview, a 65 year old man had to go to rehab to kick his oxycodone (opioid) habit that was prescribed to him to deal with his pain.  Sometimes, you have to say no to your physician and then better inform him of what you are dealing with.

After all, it is your health and your QUALITY OF LIFE.  Or occasionally get a COX blocker!  Ba dum tssh!

Fun Stuff!

Feel like being fancy?  Learn how to say OW! in different languages.  Click here.

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