Intended for healthcare professionals

Observations Ethics Man

Patience for patients

BMJ 2018; 361 doi: (Published 19 April 2018) Cite this as: BMJ 2018;361:k1715
  1. Daniel Sokol, medical ethicist and barrister
  1. 12 King’s Bench Walk, London
  1. daniel.sokol{at}
    Follow Daniel on Twitter @DanielSokol9

It is tempting to take shortcuts when dealing with patients whose English is poor

When the midwife visited the home of Sinthiya Rajatheepan the day after she gave birth, she found the baby boy lying in bed, pale and lethargic. Unfed for nearly 16 hours, he was hypoglycaemic. Although he was rushed to hospital, he developed cerebral palsy and severe disabilities.12

No one at the hospital had explained to Rajatheepan, who had just turned 21, how to feed her baby properly and what to do in the event of poor feeding.

On the day of her discharge from hospital the baby had been crying all day. None of the midwives, however, had paid much attention to mother or baby. The ward had 26 beds but just two midwives and a support worker. On discharge, Rajatheepan, a Sri Lankan national who spoke very little English, was given a folder full of papers. She did not read them, nor did she understand the 20 minute discharge discussion with the midwife. When her husband and a family friend, who had arrived at the hospital after that discussion, expressed concern about the baby’s constant crying, they were reassured by the staff that it was normal for newborn babies to cry.

On 13 April 2018 Judge Martin McKenna found the NHS trust negligent, concluding, “The reality is that no one had ever in fact given Mrs Rajatheepan a clear and understandable explanation of the importance of feeding, still less as to how she should respond if she had concerns. Because of the language barrier, Mrs Rajatheepan had been unable to communicate her concerns to hospital staff and when those concerns were communicated on the parent’s behalf by Mr Gunaratnam [a family friend] they were not acted upon.”

The judge held that, if the language barrier had been overcome, the mother and baby would have been kept in hospital overnight. The baby would probably not have developed hypoglycaemia.

Each of the midwives who interacted with Rajatheepan wrongly believed that they had overcome the language barrier through gestures and sign language.

When I taught medical students, I would ask them to name the virtues of a good doctor. Out came “competence,” “fairness,” “honesty,” “kindness,” and “compassion.” I cannot recall, however, anyone saying “patience.” Yet this may be a key virtue when dealing with patients with poor English. Life on the ward, or in the GP surgery, is so busy that the temptation for healthcare staff is to ignore, deliberately or subconsciously, the linguistic struggles of the foreign patient. To acknowledge them would mean spending much longer on the task, whether to set up a language line, arrange for an interpreter in person, or even modify their own speech to increase comprehension. It can also be tedious or frustrating.

We all know that ignoring a patient’s language difficulty is wrong. There can be no respect for patient autonomy if the patient cannot understand what we say or propose. At times, as in the sad case of Rajatheepan, patients may come to harm if they misunderstand instructions.

The hardest part is reminding ourselves not to take shortcuts when we encounter a language barrier, however tempting they may be. It is much easier to assume the patient understands, or to ignore a patient’s blank expression and other telltale signs of linguistic confusion. Silence should be a trigger to test comprehension.

Once doctors are aware of a possible language barrier, and the innate inclination to ignore it, they can then remind themselves of the neglected virtue of patience and ensure that patients understand their words of wisdom.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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