Long days without food or water: Muslim residents talk about Ramadan

At 3:30 a.m., Mansoor Ali Jatoi, DO, hits the snooze button on his alarm clock and rolls out of bed. The sky is still black as he and his wife, brother and sister meet in the kitchen to have a predawn meal. Dr. Jatoi chooses his provisions carefully—they’ll need to carry him through his 60-mile commute and nearly 12 hours of work at the hospital where he is a new intern. He eats a grilled cheese sandwich and chips, chasing them with plenty of water.

While they eat, the sky lightens. When an orange glow begins to fill the horizon, it’s time for morning prayer. Dr. Jatoi prays with his family, then gets ready for work. He’s on the road by 5 a.m., at the hospital by 6 a.m. In the internal medicine rotation of his internship, Dr. Jatoi’s day is filled with rounds, admissions and discharges and devoid of food and beverages.

By 5 p.m., when the sky starts darkening and the sun dips back toward the horizon, Dr. Jatoi feels depleted. He has less energy than usual, and he’s not feeling as sharp as he normally does. His colleague, a fellow Muslim, reminds him that it’s time to break fast. Dr. Jatoi has an apple and some water. His colleagues are eating a full meal, but he wants to eat at home with his family. Three-and-a-half hours and 60 miles later, he’s there, and falling asleep over his dinner. His wife gently prods him to finish his meal and go to bed. He’s asleep by 10 p.m., ready to start again at 3:30 a.m. the next day.

Dr. Jatoi, who will soon be a second-year resident in internal medicine at Sierra Vista Regional Health Center in Sierra Vista, Ariz., says the first two weeks of Ramadan last year were the toughest for him—his body was simultaneously adjusting to fasting and working the long hours of his new internship. But once he adapted—and started drinking coffee with his predawn meal—it was much easier to get through the day, he says.

Ramadan and residents

Islamic custom calls for Muslims to focus on their spirituality during Ramadan, the ninth month of the Islamic lunar calendar. In addition to making an effort to be more patient and charitable in their daily lives, Muslims are also expected to abstain from eating any food or drinking any beverages, including water, from sunrise to sunset. Ramadan lasts 29 to 30 days, depending on the year, and can fall during any season. This year, it starts July 8 and goes until August 7.

July happens to be the month many DOs start their internships and residencies. For Muslim DOs, fasting during Ramadan adds another layer of complexity to an already strenuous month. And while some physicians and medical students choose not to fast during stressful times, others find a way to make it work. Despite the difficulties of fasting, they say it also helps them become more disciplined and patient.

“Observing Ramadan is one of the five pillars of Islam,” says Yameen M. Rashid, DO. “If you’re a healthy walking person, you should be doing it.”

Dr. Rashid will soon start the third year of his internal medicine residency at Franciscan St. James Hospital in Olympia Fields, Ill. The biggest challenge to fasting as a resident, he says, is adjusting to working long hours without food or drink.

“I used to keep a granola bar in my pocket, so that when it’s time to break the fast, if I’m in the OR or if I’m taking care of patients, at least I’ll have something to break my fast with,” he says.

New interns and residents may want to plan ahead, he says, and consider requesting subspecialty rotations during Ramadan and Eid al-Fitr, the celebration that marks the end of Ramadan, because these rotations are typically more flexible and require fewer hours.

“As soon as I matched in 2011, I emailed the educational coordinator and made sure that during Ramadan and Eid I would have two subspecialty months, so I could take time off if I needed to without someone else having to cover for me,” he says.

Dr. Jatoi didn’t do this. As a result, he started his internship with an internal medicine rotation, which is a more strenuous rotation. He says it was tough.

“If you have difficulty adjusting to Ramadan, and we all know who we are, I would try to get a lighter rotation if possible, if your program director is understanding,” he says.

Dr. Jatoi also advises new residents not to skip breakfast like he sometimes did.

“I don’t like to eat a heavy breakfast,” he says. “But I found out the first week that I had to. If I didn’t eat a fairly good breakfast, I had a lot of difficulties by 4, 5 or 6 that day.”

Throughout the day, it becomes more and more difficult to do a lot of cerebral work for long periods of time when your last meal was close to 24 hours ago, he says.

Eating a bigger breakfast helped Dr. Jatoi adapt to Ramadan faster, as did drinking a cup of coffee with his breakfast. Muslims often forgo caffeine during Ramadan to avoid dehydrating themselves during the day, but he says one cup won’t hurt.

Some residents may shift their schedules and work fewer hours or nights until they adapt to fasting, Dr. Jatoi notes, but he says residents shouldn’t worry if that’s not an option where they are.

“It’ll be fine,” he says. “I’ve yet to hear of any intern who didn’t have a supportive program.”

Fasting is not as bad as new residents likely fear it to be, Dr. Rashid says.

“The thing that a lot of people fasting need to realize is that this is temporary,” Dr. Rashid says. “We do this for many, many reasons, and one of the main reasons is some people go days without eating not because they have a choice, but because they don’t have a choice. Knowing that when I come home I will be able to break my fast and I will go on living my life after this month gives me enough motivation to not let this affect me.”

Some of his friends don’t fast when they have demanding workloads, he says, instead making up the time later. But he doesn’t think residency is a valid reason to skip fasting.

“Don’t use residency as an excuse not to fast because it won’t affect you that much,” he says. “If anything, it is actually a good conversation starter. A lot of times people will say, ‘Oh, you’re fasting. Tell me more about it. Tell me more about Ramadan.’ “

‘It could be much worse’

Myra A. Zeb, OMS III, the Edward Via College of Osteopathic Medicine-Carolinas Campus in Spartanburg, S.C., wanted to help her classmates and professors better understand Ramadan. As the president of the VCOM-Carolinas Islamic Medical Assocation, she collaborated with other members of the group to hold a “Fastathon” at school in which all students and faculty were invited to fast with Muslim students for a day.

“We had donors sponsor everyone fasting, and we ended up raising $1,000,” Zeb says. “We gave everyone a big free dinner at the end, and we had speakers explain why we fast.”

Fifty non-Muslim students fasted, Zeb says, and the money was donated to Doctors Worldwide, a nonprofit dedicated to providing medical care in underserved countries.

The key to successful fasting in medical school, Zeb says, is finding support from others who are also fasting. Focusing on the big picture is crucial as well, she says.

“Always know that it could be much worse,” she says. “There are people around the world who go through this every day, who don’t have food, or who are probably working outside, and they’re still fasting.”

Like Dr. Jatoi, Zeb suggests fasting medical students wake up before sunrise to eat and make sure to have plenty of protein and water in the morning.

Sarwat Makkani, OMS IV, of the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth, agrees. During Ramadan, students may want to shift their schedules too, she says.

“On the weekends, I would sleep during the day and study the whole night,” she says, “And that definitely helped me a lot.”

But everyone handles Ramadan fasting differently, Makkani notes.

“Students have to figure out on their own what works and what doesn’t work for them,” she says.

How fasting helps

As new medical students and residents navigate Ramadan for the first time, they may find that fasting brings as many benefits as it does challenges.

“In general, fasting teaches endurance, stamina and patience,” Makkani says. “Good physicians have all three of these qualities.”

During Ramadan, Muslims try to better themselves, Dr. Jatoi says, so they tend to go above and beyond in every area of their lives, including work.

“I’m more prone to accommodate others as much as I possibly can and to try to make everyone around me happy as much as I can,” he says. “Sometimes you’re a traditional intern, who’s just grumpy. But during Ramadan, I try not to be aggressive or upset.”

Dr. Rashid says observing Ramadan helps him improve his bedside manner.

“Ramadan is a time for you to change the way you act, the way you treat others,” he says. “If you’re dealing with a difficult patient, it teaches you to be more disciplined, more patient. Sometimes it’s frustrating when you’re not able to figure out what’s going on with the patient, or if you’re in the ICU and patients are getting worse when they should be getting better. Ramadan makes you stronger as a person, and it makes you expect things to get better.”