In the Halls of the Hospital: My Decision Not to Fast this Ramadan

I’m a resident in Internal Medicine at the University of Toronto and, on July 2nd, I started my first shift as a doctor. It was a 26-hour shift that included a night jam-packed with running between sick patients while thumbing through my textbook to make sure I didn’t miss an important investigation or treatment. As a resident, the amount of time I spend in the hospital is rarely under my control. The week is often long, occasionally upwards of 80 hours. My training program sure knows how to throw us straight into the deep end.

The transition from medical student to resident feels a little intense. I didn’t get any smarter from one day to the next, but now have an enormous amount of power and responsibility. Sure, there are residents with a year or two more experience just a phone call away. But when crap hits the fan and a patient gets acutely ill, I hope I’m competent enough not to make critical mistakes. Part of the learning curve is developing clinical judgement and I’d really prefer not to do that at the expense of a patient’s health.

I swear, my anxieties aren’t baseless. Some staff physicians and nurses nervously chuckle about “The July Effect,” a phenomenon that suggests hospitalized patients experience higher rates of morbidity and mortality as a result of all those new MDs starting their residency at the same time. Fortunately, recent research suggests the effect is likely not that dramatic, but it’s hard to deny that patient care may not be optimal in July. Mistakes are more likely to get made. Issues can get missed. Good care just takes longer to provide.

With all of this weighing on me, I made an explicit decision not to fast this Ramadan. I grew up fasting with my family every year, without fail. I still remember our daily pre-dawn routine, my mother jostling my brother and me to wake up in time for a bite, while I suggested I’d be fine fasting without a proper breakfast. But that was way back in the day when Ramadan fell in the heart of the Canadian winter, only about 10 hours from sunrise to sunset.  In Toronto now, time for Suhoor ends at 3:30 am and Maghrib falls around 8:55 pm, a fast that totals over 17 hours. That’s a long time without food and water. Let’s be honest; my brain has a hard time functioning without caffeine. Without a mid-day meal and adequate hydration, it’s practically mush. Knowing full well I’m already error-prone, I can’t possibly fast and still provide patient care optimal to my capacity.

My step-dad seems to think he should fast under all circumstances, come hell or high water. He works 12-hour shifts, managing a propane station and his Type 2 Diabetes. Despite that he is exempt from fasting, my step-dad thinks God will protect him from episodes of hypoglycemia and a possible coma. I, on the other hand, am not so sure.

Part of fasting, I think, is accepting the reality that our bodies will slow down in the absence of sustenance.  Slowing down, in and of itself, is the annual gift. In that way, Ramadan always anchored the reset button in my life. The discipline inherent in fasting gives me 30 days to be deliberately conscientious about the space and place God takes within my day and fills my spiritual tank. By the time I’m running on empty, nearly a year has gone by and the next Ramadan is creeping up quick.

Yet, in this new life as a resident, my life is not entirely my own and I can’t slow down. I have memories of my Ramadans as an elementary school kid in Saudi Arabia. Schools ran shortened schedules. Retail and grocery stores stayed closed for most of the day. Most people cut their working hours and often limited them to after iftar. In the context of the Western world, where the vast majority of the population doesn’t observe Ramadan, I have a hard time justifying a spiritual practice that may detrimentally affect the quality of clinical care I provide to others. In the absence of a health issue, I get that I’m not exempt from the religious obligation to fast according to most Islamic thought. At the same time, I have specific performance obligations to the training program that hired me and, more importantly, particular care responsibilities to the patients I see.

This month, I’m redefining the parameters of my practice. While I’ve decided not to fast, I still need to refill my proverbial tank. Yes, I’m spending a little extra time on prayer and remembrance, even if it’s on the 20-minute bus ride into work. I’m trying to recite my tasbih climbing the stairs. I’m saying a quick “Bismillah” before I review a patient’s chart. But shoving a little bit of Arabic into my day-to-day life doesn’t feel like it does Ramadan justice. Instead, I also want to think deeply about the kind of patient care I want to provide.

My mother always underscored that our devotion to God is truly reflected in our devotion to humanity. If I’m spending so much time in the halls of the hospital, it’s also time for me to start thinking about my clinical practice as a parallel to my spiritual practice. No, I will not be walking into patient rooms trying to convert people to Islam. I am bound by fard, however, to treat each patient with deep love and compassion. I’m also obligated to be honest about the boundaries of my expertise and exercise humility in the face of my limitations. Maybe by the time Ramadan falls in the Canadian summers again, I’ll be old hat at this Internal Medicine thing and fasting won’t compromise the patient care I provide. Until then, at least in my world, Ramadan will likely look a little different.

For more on MMW’s Ramadan series, and to read the rest of this year’s Ramadan posts, click here.

  • Abduljabbar Suhail

    all I can say is that you have fasted a few days before deciding whether you could do it or not instead of not making an attempt at all.

    • Walaa Katoue

      I agree. This Ramadan, I am nursing my son this year and my husband has Type 2 diabetes and we are both exempt. Nevertheless, even after obtaining fatwahs of pardon, we decided to try a few days at the beginning due to the severe warnings of breaking a fast intentionally and without a valid excuse. My husband was able to continue and alhamdulillah his A1C levels shocked us all, they’ve never been this low. I was not quite so lucky with my milk supply and so I’ve stopped. My best is advise is to seek the advise of a mufti you trust. Sheikh Navaid Aziz (you can find him on Facebook) will give you a fatwa that is in accordance with Ahl al Sunnah wa Al ghamaaja, if you are interested.

      • Faith Barrow-Waheed

        Alhamdulillah, my mother, who also has Type 2 diabetes has been able to fast as well. Her numbers have also been great.

  • Laissouf Ayoub

    I think your decision is wrong my friend because when I compare you with the people who are working in my country in construction with shovels under the burning sun every day in Ramadan from 6 AM until breakfast, your situation seems nothing compares to them. you are working in a clinic which is equipped with air
    conditions. You will not even suffer from the heat of the summer, and you decide to not fast. When I read your article, I feel like you are looking for an excuse. Think about my friend and repent to your God.

  • Anees

    Thanks for this piece Sr. Amina. Insha’allah, I’ll be a resident next year at this time. I’ve already faced these issues while taking the American board exams the last year and half. It was nice to get your view on this experience. Wishing you the best both professionally and personally/spiritually.

  • Afreen Pappa

    As a physician myself, I completely understand the toll fasting takes on your ability to think clearly and make sound decisions in dealing with the health and often life and death decisions for another human being. Many people may not agree with your decision (as they have not walked in your shoes), however, it should be respected as a decision you made after careful deliberation. There is no compulsion in Islam. Allah is the best judge of a person’s intentions. Many people may fast regularly, but still engage in behavior 11 months out of the year that does not demonstrate that they learned anything during the month of Ramadan. Do not be disheartened by them. It is easy to be critical. It is harder to be compassionate and respectful of a person’s personal decision.

  • Natasha

    Me: I’m debating not fasting when I take my Bar Exam.

    Imam: I fasted through basic training when I was in the Navy. Focus on weaning yourself off caffeine and keeping your mind sharp when taking your exam. InshaAllah, you will pass, and He will place barakah in your attempts to become a licensed attorney.

  • cncz

    I love how these people come on here judging you like this isn’t a choice the author has thought long and hard about. Good way to take away people’s agency, judgy mcjudgersons, and i hope you people never have any tough calls in life.

    • Walaa Katoue

      Where you see judgement, I see concern and very respectfully worded advise. There’s no need for name-calling.

      • cncz

        I don’t see me name calling but I see a lot of you judging. In fact, I hope when you are in a tough situation in cha Allah you will be surrounded by people of understanding and not judgment, ameen.

        • Walaa Katoue

          “way to take away people’s agency, judgy mcjudgersons”….?

          Right. I fail to see anything wrong with advising someone to seek professional advise, especially in a situation that is so delicate. Wallahu ta3al a3lam.

          • cncz

            I take
            offense that every bit of your “advice” comes from a starting point that the author either hasn’t thought long and hard about this decision, or didn’t try enough (not your call to make), or doesn’t have the deeeni tools to face the decision (e.g. your suggestion about a fatwa). When you give “advice” like that, your prejudice shows.

            Check your intention. May we all as an ummah check our intentions before going after other people’s choices. Ameen.

            Just because she made a choice you wouldn’t have made, it doesn’t mean it wasn’t informed. I love it when muslims give judgment, call it advice, then act offended when they get called out on it, and then call out other people for supposedly not acting right.

            Allahou alim right back…I’m done feeding this concern troll. Wa salam.

          • Walaa Katoue

            Thank you for your advise; it’s always good to check our intentions and Ameen! May Allah grant us clarity, starting with this ‘concern troll.’

            Before this exchange deteriorates any further I will just conclude with this ayah “So ask the people of knowledge if you know not.” [16:43] To the author of this post, I’m not suggesting you take my advise in regard to whether or not you should fast; I provided an anecdote above regarding how difficult that decision was for me this Ramadan. Rather seek the advise of those who have the knowledge to advise you.

            Wa Salaam to you too cncz. Ramadan Mubarak!

  • mathgeek

    Disclaimer: I’m NOT trying to say that the author’s decision, or anyone else’s, is right or wrong… I am simply sharing my experience this month, which has left me in awe at the Mercy of my creator!!!
    Read this peice after my sister sent it to me… Who kept hearing about my struggles / doubts / complaints about being an internal medicine intern this Ramadan. I started on June 25th, and was a little (read: A LOT) nervous about Ramadan approaching, especially given the fact that I would be starting my ICU rotation on the first day of Ramadan (hardest rotation I will face this year), where the hours are long (averaged about 84 hrs a week so far), the patients are sicker than sick, and the rounds are brutal (longest so far has been 11 hours!). To make matters worse, I get very bad migraines anytime I am sleep deprived / hungry / stressed out.. And I live with my Triptan meds in my pocket, ready to swallow at the onset of any migraine. So from my perspective, for the first year in my life… I really was not looking forward to Ramadan. I decided to place my trust in God, and try it out – worst case scenario, I could break my fast if I needed to (if I felt that I was truly compromising patient care). On the first day of my rotation, when I was offered lunch and refused because I was fasting (in retrospect, sometimes I think I shouldn’t have announced my fast to everyone that day!), the entire team looked at me like I was crazy. Upper residents told me: if you’re gonna do that anywhere, I would NOT do it in the ICU! I could only guess what the quiet ones were thinking. A nurse later told me: when they called that code on the floor, I thought it was for you! Despite everything, of course everyone respected my decision, and I assured them that patient care comes first, even in my deen, and that I would break my fast if I needed to. Now, halfway through Ramadan, I have to say that Allah has helped me in ways I cannot even imagine. Yes, I had to take medication prophylactic ally at suhoor for my migraines, and yes occasionally I did get migraines near the end of my shifts, which I tried to “toughen out” until Iftar time (I haven’t broken my fast so far, alhamdulillah though I probably could have when I had the migraines). Yes, I was hungry and sleepy at times, when others were basically running on caffeine and sugar all day. But fasting gave me a clarity of mind and an energy that BLEW me AWAY! Subhanallah, I was able to think and focus SO much more on my patients without the distraction of food/drink. To the surprise of my team, I was able to put in as much energy and work as everyone else… In fact, more than what was required. Because I was constantly in such a vulnerable state, Allah was always on my mind, I was *constantly* making Dua throughout the day; I was forced into a beautiful humbled position before Allah, constantly asking Him to make things easy for me as I was trying to follow His commandment of observing the fast. I was constantly reminded about why I was fasting, and felt that Allah gave me power and energy that I had no idea I could have! There were many many examples of Allah helping me / answering my duas, I can’t even begin to list them – they may be tiny or minuscule or “coincidences” in some people’s eyes but to me, they made a world of a difference, and reminded me that Allah was on my side. It all hit home when I received feedback from my upper residents/attending yesterday – I was shocked with what the had to say. All this time, I thought I was scraping by, but the comments they gave me were outstanding. Ironically my attending stated: “out of all the residents and fellows on the team, you were able to learn the fastest. Your ears were open. You were focused and taking it all in, and I only had to say something once, and then you got it! It was done! Which really surprised me because as an intern you are struggling to learn the system and have all these new responsibilities, and usually are not able to grasp as much knowledge!” … I’m only sharing this because I honestly believe, this came from Allah, not from me. As an intern, we all know just how competent we can be at taking care of patients sometimes ;) (yes that was sarcastic). Perhaps fasting helped clear my mind and allowed me to tap into my “inner energy”. All I know at this point, is that I placed my trust fully in Allah, at a time when no one could help me, no food or caffeine or medication could save me… And the outcome was only befitting of my Great and All-Mighty Lord!
    “And whoever fears Allah – He will make for him a way out. And will provide for him from where he does not expect. And whoever relies upon Allah – then He is sufficient for him. Indeed, Allah will accomplish His purpose. Allah has already set for everything a [decreed] extent” {Al-Talaaq, verses 2-3}
    PS I am not advocating for everyone to fast at all circumstances. Again, just sharing my experience, in case it helps someone out :)

    • Student

      Rather than judge, you presented a beautiful reflection of the other side of the story. Thank you for that.

  • wjshelton

    Well said. Thank you.

  • Ranu

    My Hubby is a great example…. he is a physician with many attachments, but all these years never did i see him miss a fast.. including taraweehs and including few times when he never wakes me up amd warms up the sahoor food..and sometimes if home makes iftaari.. my husband is a great muslim and justifies his role as a muslim and a husband too… i think its a matter of faith

  • Ali Furqan

    Great Article..You bring up an excellent issue. I am a medical resident myself and can empathize with your situation. You have an obligation to the safety and well being of your patients, and should not be fasting if it affects the patient care you provide. Protection of life and health is one of the highest priorities of shariah

  • Aziz Sadiq

    As a new surgical resident, I remember facing the same difficulties. The hours are long, unpredictable and eating is never planned. This goes for the other 11 months outside of Ramadhan. It is not my position to tell you what is wrong and right, but my hope is merely to share my experience and possibly see Ramadhan from a different perspective

    My wife and I recently celebrated our sons 2nd birthday and I can’t help but remember the position I was in when he was born. He was born on the 30th of Shaaban and 1 month premature. This would eventually mean many sleepless nights at home AND at work when I would take 24+ hour shifts. On top of that, he was born on the heels of the month of Ramadhan and in July when I would be starting my surgical residency.

    As surgeons, we are told to lead, even within the medical field. We work in a culture of arrogance, where the rules do not apply to us. We work harder and longer than the next doctor. This culture of “macho-surgeons” still exists today, whether we like it or not. Like doctors in other fields, we are required to make decisions that ultimately dictate the lives of our patients. As a resident, we are supposed to make the right decision, but there is a system of checks and balances because no one wants their life to be determined by a resident 1-2 years out of medical school. There are chief residents available, and attendings who ultimately make the final decision. I learned quickly, that a new resident is merely a liaison who helps in the overall medical care.

    With that said, I recall my decision to fast during Ramadhan because I was responding to a call from the creator, and not the created. With this motto in mind, I was able to focus at work and eventually at home when it was difficult to fast and help with a new born. I knew I was being tested. My dedication to my faith, family and career were testing me. With the many other tests we face in life, I took the belief that we are only tested that which we can handle.

    Only by the grace and help of God, was I able to survive the trying month. I look back at that time and I wish I could do it again. It was a true test of faith and I am stronger for it. I believe the spirit of Ramadhan is just that, testing your faith for a better outcome. I am grateful for the support of my family and collegues, but most of all the guidance of Allah truly helped me in a trying a month.


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