When an ailing 75-year-old woman succumbed to heart failure after two weeks in intensive care, it fell to young physician Sandeep Amale to break the news to her sons. They did not take it well.
One marched out of the suburban Mumbai hospital and barked at a security guard, "I will see these people again." He soon returned with relatives, who attacked Amale outside the intensive care ward, leaving him with fractures in his nose and foot as two dozen hospital staffers looked on helplessly.
The incident in April was one of a string of attacks on Indian doctors and medical staff members, most of them by angry friends and relatives of patients. The threats have become so serious that one doctors organization this month enlisted an on-call private security company, whose website features testimonials from Bollywood stars and political figures, to protect 4,000 of its members.
The company, Topsline, whose motto is, "We Save Lives," promises to respond to emergency calls within 15 minutes. Under the new policy it would shield doctors from physical harm, although its personnel are not authorized to use force.
"Such security would have helped in my case," said Amale, who has recovered from his injuries but left the hospital to start a private practice. "Things are going from bad to worse for doctors."
Unlike their counterparts in the United States, where physical attacks on medical professionals are rare, doctors in India appear to be at growing risk. The Indian Medical Assn. found in a recent survey that more than three-quarters of doctors had faced violence or verbal abuse at work.
The problem stems from a lack of trust between patients' families and doctors, industry groups say. As India's economy booms, the quality of healthcare available to the aspiring middle class has increased, along with its cost. That has made it more difficult for people to accept when patients don't get better.
"There is an increasing expectation from patients that with modern medicine and technology, a doctor should be able to guarantee a good outcome," said Sudhir Naik, president of the Assn. of Medical Consultants, which hired the security company.
"The perception is that any adverse outcome is due to the doctor's negligence."
At the same time, tales of corruption and carelessness at medical colleges and among practicing doctors have spread through the country, prompting growing skepticism among Indians of a profession that has long been revered here.
Healthcare advocacy groups complain that Indian medical schools don't teach communication skills, producing graduates who can't explain procedures in plain language. Worse, some doctors have been found trying to pad their earnings by performing unnecessary procedures or ordering excessive tests. Since the vast majority of Indians pay out of pocket for healthcare, they wind up footing the inflated bill.
In November, more than a dozen women died after undergoing sterilization surgery at a rural clinic. This year has brought disturbing revelations about a testing scandal in central India in which at least 2,000 students cheated their way into medical colleges.
"Almost everybody in the country has been a victim of some form of graft or malpractice — be it inflated bills, wrong diagnosis or substandard treatment," Down to Earth, a science magazine, declared last year.
Doctors, especially in government hospitals, counter that they are overworked and underpaid. Shoddy medical infrastructure, including a dearth of well-equipped emergency vehicles, means that many patients reach hospitals too late to be saved.
"No doubt there are black sheep," Naik said, "but because of these few instances, the entire profession is being painted with this brush."
As the assaults have stacked up, some groups have sought ad hoc solutions.
In mid-April, a doctor was beaten at a hospital in the northern city of Allahabad by the family of an 80-year-old patient who died of complications from kidney failure. Closed-circuit TV images of the assault went viral and prompted a protest by doctors that briefly shut down medical care in the city.
Days later, after a doctor and an orderly were manhandled by patients' relatives in a Mumbai public hospital, the hospital director beefed up security for the staff by hiring 40 private guards, termed "bouncers" in local news reports.
Sanjay Nagral, a surgeon and editorial board member of the Indian Journal of Medical Ethics, said attacks on doctors were deplorable but lamented the turn toward hired muscle.
"The answer does not lie in increased policing and security," Nagral wrote in a commentary in the Mumbai Mirror newspaper. "That may worsen the already eroding trust that is so critical for the credibility of the medical profession's ability to deliver healthcare."
After the attack that injured Amale and another doctor at a private hospital in Panvel, east of India's financial capital, doctors in the city set up a hotline. Anytime a doctor sensed that he or she faced danger, a call would alert colleagues.
Ironically, Amale said, he initially helped save the elderly Namubai Thakkur, the patient whose demise prompted the attack. When she was admitted one night in March with a serious infection, gasping for air, the 32-year-old physician helped clear her airways and she was moved out of intensive care for a few days, until her condition deteriorated again and she eventually died.
Amale said police officers initially sided with his assailants and refused to take his statement. In the end, the culprits were detained briefly and released.
Doctors say a 2010 law mandating punishment for attacks on medical workers in the western state of Maharashtra, which includes Mumbai, has not been enforced.
They also complain about entitled attitudes of patients, particularly in places such as Panvel, a onetime agricultural area that is now a boomtown suburb, bursting with giant apartment blocks. As land prices soar, farming families have become urbanites almost overnight, often harboring what doctors say are unrealistic expectations.
"Panvel is full of Audis. Any car you see in America, you can find in Panvel," Amale said. "They think they can buy anything with money, including the life of the patient."
He hopes never to work in an ICU again. After quitting his relatively well-paying hospital job, he opened a 15-bed private facility with his wife, a pediatrician. They have barely begun to break even, but he is relieved because their clinic doesn't see emergency patients, the life-and-death cases that surveys show cause as many as half the violent incidents.
"After four or five years, doctors will lose all their confidence because of this violence," Amale said. "It will culminate in doctors thinking that this country doesn't deserve doctors."