Germany is relying more on foreign doctors to fix a crunch in its healthcare system but a notoriously daunting language barrier is complicating patient care, with potentially disastrous results.
State authorities and industry groups are pushing for stricter language tests for new arrivals to ensure that along with their medical credentials, doctors can adequately communicate with Germans in their care.
Germany, Europe's top economy, is streamlining immigration and certification rules to attract foreign doctors.
But critics say the language requirements in most states do not guarantee this influx of foreign doctors can talk with and understand patients.
"It's a problem, a growing problem in Germany," Hartwig Meyer, a lawyer and head of the German Patient Protection Association, told AFP.
"There are many doctors who come from abroad, and they speak only very poor German."
The percentage of foreign-born doctors practising in Germany climbed to about 15 percent in 2012 from around five percent in 2007, according to the German Medical Association, as a strong economy and doctor shortages in small towns and rural areas pull practitioners from Greece, Romania and Poland.
Recent news reports have spotlighted stories of patients like Volker Mikat, 49, from the western German town of Guetersloh, who is suing the hospital where he received stomach surgery after claiming his doctor's explanation of the operation's risks was incomprehensible.
"When I asked a question about alternatives, he couldn't answer me at all, I think because he couldn't understand me," Mikat told public broadcaster ARD, which did not reveal the doctor's nationality.
Hartwig Meyer said he files a few similar cases for clients each year, but no reliable statistics exist to indicate whether these are isolated incidents or part of a larger problem.
Worried there would be an emergency
Many foreigners learning German complain of the devilish complexity of its grammar and vocabulary, with language a key obstacle for Germany in trying to fill a critical skilled labour shortage.
Iranian doctor Hengameh Bigdeli, 45, took a six-month intensive German course before starting work near Nuremberg, but still found the language's structure frustrating.
"When I first started working, I was really worried that there would be an emergency and I wouldn't be able to understand the patient," Bigdeli said.
"But when I had a problem, I asked the patient to repeat, to speak clearly and slowly, and they repeated and repeated until I could understand."
After two months working, Bigdeli said she no longer had any communication problems.
But because of qualification differences in her home country, Bigdeli, who immigrated to Germany three years ago, must work as an assistant doctor.
"After 14 years of working independently, having my own practice in Iran, it was hard to be like a student again, working under a supervising doctor, never being able to make decisions alone. It's hard, but better than nothing."
Germany has a particularly acute need for doctors from abroad as their local counterparts age and retire, but "it's hard for patients, because they worry that their doctor doesn't understand them," said Armin Ehl, managing director of the doctors' union Marburger Bund.
"There are some medical departments in rural areas, where besides the head doctor, there are only foreign doctors," Ehl, whose organisation is lobbying for a standardised, nationwide language test for immigrant doctors, told AFP.
A report by an industry group in December indicated that there were around 2,600 too few general practitioners in Germany last year, with another 2,000 specialists lacking.
Fluid European Union borders mean immigration among doctors has become commonplace, fuelling worries about quality of care.
In Britain, a patient died in 2008 after German doctor Daniel Ubani administered an overdose of painkiller on his first shift there.
Following the accident, British officials announced last year they plan to require English tests for doctors immigrating from Europe.
'Chaos in Germany now'
Sweden's medical association is asking for a review of its language policies, which currently only require proof of proficiency for those educated outside the EU.
Austria requires mock-patient interviews for immigrating doctors.
In Germany, language requirements for foreign-trained doctors vary in each of its 16 states.
Most require a certificate proving German ability at least at the common European "B2" or "upper intermediate" level, according to Ehl, but not a separate test of medical terminology.
"Someone who has a B2 certificate can certainly buy a sausage, or a train or plane ticket in Germany, but there is no guarantee that he can communicate with a patient," said Juergen Hoffart, head of the medical association for Rhineland-Palatinate, which last year became the first state to require German tests with mock patients.
Germany's most-populous state, North Rhine-Westphalia, is following suit this month.
Meanwhile, Germany's health ministers agreed last summer that a uniform review process for language skills should be developed.
Matthias Klug, who runs integration courses for doctors in the southern city of Nuremberg, is sceptical the complicated regulations will be standardised.
"We have chaos in Germany now," Klug said. "Every state does something different, it's like the Middle Ages."