Friday, August 31, 2012

Illegitimate Daughter

As salaam alaikum,

If any of you couldn't tell, I got some daddy issues with Islam.

Some major daddy issues.

When I came into practice in late 2003 after growing up in an interfaith household, I searched for a way to bring meaning and sense to my world, a world that, in my teenage mind, tended a little too much towards chaos. Without having ever read the entire Qur'an myself or having gotten any religious instruction outside of what my mother taught me, I didn't understand how a just and merciful god could allow such suffering in the world.

Of course, being a teenager and just journeying into the world of abstract thought, I had no idea that this was a major philosophical question that has puzzled people for eons before my time, the answer of which has led many before me on several paths between devotion and atheism.

Of course, my life was good. I was an upper middle class kid from a semi-rural small town who had nearly everything she wanted. It wasn't just given to me, mind you...I afforded college because of merit scholarships, not Daddy's money. And of course, the grace of God, which I was spiritual enough to recognize at the time, but I wanted more. I was plagued by my own emotions, my own angst. If I was suffering so much from things just in my head, I could only imagine what it must be like for people with real suffering...women and girls subject to rape and sexual assault on regular bases, people starving, people without homes. It just caused me to delve deeper into a downward spiral of despair. If God didn't help these people who obviously needed it more than me, why would he ever help me who had the "fake" problem of depression?

So, as I entered college, I searched for more solid standing within Islam, to provide me with a much needed foundation for my spirituality, and to provide me with comfortable answers to my questions about the nature of God. Submission to God was the answer for me, and that would solve the problem of my depression and anxiety.

I was so not expecting to come into an Islam, practiced by Muslims I've encountered here in the United States, that would not always be that comfortable place to seek refuge, to submit to God, to rest my weary spirit from the unforgivable secular world.

I wasn't expecting to find out I was, in fact, an illegitimate daughter of Islam.

Sometimes, just sometimes, I wish I had remained in a state of innocence. I wish Islam had remained for me as simple and organic as my mother taught it. As I delved into Islam in college, I came upon a version of Islam that was at times hostile, inflexible and merciless. It felt very much unlike the way I was raised to believe in God, the Most Gracious, Most Merciful of my Yusus Ali translation of the Qur'an that my mother used to read to us when we were little.

It wasn't the first sticking point, but the most painful sticking point was the fact that my parents' marriage, under most interpretations of Islamic law, is invalid, because my father is not Muslim.

So I am illegitimate.

I mean, for a while, it didn't really matter, because people would see me at MSA meetings and think I was a non-Muslim interloper anyway, because I was black. Never mind that the first major populations of Muslims in this country were black. Never mind that the first president of the MSA at my college years ago was a black woman. How strange to enter a context in your own country where you are made to feel foreign when, as a Muslimah, especially a searching, striving Muslimah, I should have been made to feel welcome.

I'm always an outsider because my name and ethnicity make me a mystery. I always have to explain how I was raised Muslim.

So it hurts to be considered otherwise illegitimate by my coreligionists.

I struggled to find a way in a faith, as I understood it, that would require me to deny my father, or deny his culture, in a certain sense, if the culture considered itself diametrically opposed to Islam. Maybe it was the fact that I was exposed to Muslims on my mother's side that were not so rigid that I did not go down that road that many of those that come into the religion later in life do.

Maybe it was the fact that it was partially the values that my father raised me with that brought me to Islam. So how could I rebuke the man who was responsible for bringing me into the world and partially responsible for my Islam? It made no sense...

I could easily give up on a religion that always considered my parents' union, the union responsible for my life, illegitimate. I was always a bastard, anyway, so why even bother? Why even bother, if God never blessed my parents' union? Why even bother, if I'm completely dispensable in a community of believers, believers, the best of communities of people in this earth, because my ethnicity isn't usual, because my name isn't right? Believers will continue to strive in the way of Allah (swt) and insha'Allah find their reward with Him in paradise without missing the little misfit that either sat, tugging at her sleeves without hijab in the center of the room or sat, tugging at her sleeves with hijab at the corner of the room, spoken to by only a couple of sisters that took pity on her isolation.

I've given up on a few things over time, but alhamdulillah it never leaves me with nothing. When I let go of everything, I'm left with the simple, organic Islam my mother taught me, and Islam that would make sense for an illegitimate daughter like me to practice...illegitimate in the sense that I'm living here in a non-Muslim country, as an ultimate minority, irremediably and unabashedly American, beautifully black and proud, unlikely to fit in a country perceived to be more halal for me because of all the things that I am, unlikely to fit into Random Muslim Community USA because all of the things that I am...

My mother became expert at practicing Islam in almost complete isolation. And while I will not stay so isolated, this is the Islam for me, free of some of the toxic impurities that we have somehow absorbed over time and taken as dogma.

So yes, I grew up in Islam without a Muslim father, without a "father." But I think my fellow Muslims make huge mistakes in this life when they ignore people like me who are several ways "illegitimate." I think if we do this, we're missing the point, we're missing the purpose of life, we're missing out on blessings and we're missing out on forgiveness.

Thursday, August 16, 2012

All I Want for Ramadan

As salaam alaikum,

As I approach my last two nights of the night shift, I find myself getting accustomed to being a day zombie and night warrior. And by night warrior, I mean ambling around the hospital at 2am to answer a page about a patient, wrapping my fleece around me to prevent the shivers as my body tries to convince me to sleep.

Anyway, I'll be glad when nights end. I spend most of my morning sleeping then most of my day lounging around. My seniors suggest that I do nights next year during Ramadan, because that would "be perfect." No, thank you. There are various reasons why Ramadan this year was a little haphazard (or a lot haphazard, heh) compared to years past, part of that is my fault, but night shift disrupts Ramadan for me. It disrupts the spirit of fasting if I'm sleeping part of the day away to work a 12 hour shift at night.

Plus, it's very hard to sleep during the day without taking sleep aids, and if you're fasting, you can't take sleep aids. Having to stop eating by 4:30am also means no caffeine to get you through the rest of your shift when you have to go until 11:00am (that's me on Saturday, iA!).

So no, night shift is not ideal for Ramadan. Next year, iA, I'll do an outpatient month or something. That way, I'll be sure to be able to do my reading that year. Insha'Allah I also plan to check out the mosque in Northgate at some point; looks like Eid is going to be held at a convention center. Having a car makes this easier, but working most days does not help.

Ramadan has been a little bit isolated this year because I don't have my medical school Muslim group weekly iftars or local MSA events to sample, but interestingly, it's been one of my least lonely Ramadans on record. I am super happy about my residency program, I've made family here with my co-residents, I'm learning a lot...I've given up on marriage...

And really, I could not be happier.

Ramadan for me is not only a time of reflection, of prayer, of God-consciousness, of self-control, but it's also always been a miraculous time for me. It's a time when Satan is at bay, when God will answer all of the prayers of those who fast and remember Him...and I take advantage of that every year to pray for myself and my family, about anything that's going on in the world, anything pressing.

Because while I believe that God always answers prayers, I felt like Ramadan held greater promise. Ramadan, I was more focused.

So for the last several Ramadans, many of my prayers had to do with marriage, future spouses, etc. Every salat with some istikhara in between. And every year, the same yield. But I was convinced that when the time was actually right, God would provide. I always am, always will be. Unless it is not God's desire for me to marry, which is also a possibility.

But if Ramadan is a time when all of your prayers are answered, why is this one never answered? Was I doing things incorrectly? Did I wait too long to make up my missed days from menstruation?

The fact of the matter is...Ramadan is still a special time for me, a time when God's grace feels ever nearer. But it's just like every other day of the year when prayers are not answered in a way that is apparent to you or in a time that is what you desire. Every other prayer I've prayed to God has been answered in a self-evident way. When I prayed about marriage, all I got was an empty feeling in return.

So I gave up. I prayed about it in the beginning of Ramadan, but I lost heart. I lost heart and I lost resolve. And maybe it's okay. Ramadan isn't like my personal Christmas and God is not Santa Claus. Ramadan is greater and God is Greater and why I couldn't get married is just something I'll never understand.

So I didn't want anything in particular this Ramadan, but the preservation of the blessings I've already been given. Health, vitality, that of my family and friends, safety...the ability to carry out my duties as a new physician, the intellect necessary to improve as time goes on...

And I pray for a better Ramadan next year, one that is more replete with God-consciousness and in that, blessings for myself and my loved ones. One that is more pure, not as disjoint and interrupted as this one has been. I should give myself somewhat of a break, because I changed cities and am working for the first time, but on the other hand, it's so disjoint because of deliberate choices that I've made...

All I want for Ramadan is for God to have mercy on me as I stumble forward in life, being less the woman I had the potential to be, being less the believer that I can be, making mistakes...getting lost. Being my worse enemy. Realizing my personal failure.

Sunday, August 12, 2012

Day in the Life of a Family Medicine Intern

As salaam alaikum,

It's been a while! Between being behind on my Qur'an reading this Ramadan and rotating through inpatient medicine, that supposedly gives me four days off, but two of those days are, like, 7pm-7pm days off (cheating!), I haven't had time to just sit down and chit-chat.

That, and this whole living one day at a time thing has led me to make some interesting life decisions that I have to process in a less public forum. It happens from time to time! I will be back, insha'Allah.

But alhamdulillah, I'm blessed to be in a wonderful residency program that suits all of my needs surrounded by loving co-residents and super supportive faculty, indeed, everything I need. I do miss home from time to time, especially after spending one month there before moving out west, but I recognize that I'm realizing part of my purpose of life by being here.

A while back, I asked if anyone had any questions about me that I don't address here, and the only question that came from that query (I'm still open to any!) was for me to describe a day in the life of an intern. I told that person, who posted anonymously (so I'm not sure who you are...hopefully you're still reading!) that I would wait until I was in the thick of my inpatient rotation and get back to you. So here I am, in the thick of my inpatient rotation, getting back to you.

You asked for a day in the life. I'll give you a day. I'm about to start night shift for six days...that should be really interesting, as well. For the sake of HIPPA, I'm not detailing anything about my patients. This is a public blog and I think the reason that I don't really post about the hospital is because HIPPA is sticky business. I'm also not going to give any hospital identifiers, etc. But it's fairly representative of my day, anyway, hehe.

So, I was on call last Sunday. Call isn't properly call any more. Back when I was a medical student, call meant overnight call, 24 hours. As an intern, you would come in at 12pm on one day and leave 12pm the next. This was awesome as compared to the days of 30-hour call that most of my attendings were trained in. As a medical student at the general hospital, our call was 10am to 12pm, because we had to be present for teaching. Sometimes we'd be in the hospital from 7am to 5pm, though, because of required classes.

So, last Sunday, I did weekend day call, from 6:30am to 8pm. Not bad at all. Even better than my Sub-I, where weekend call was 6:30am and you admitted patients until 8pm, so you could very well leave at 11pm or however long it took you to finish working up your patient.

But I don't mind the 6:30am to 8pm call on the weekends because this inpatient service is Q3, meaning you're doing long day call every three days. All other systems I worked in, you were Q4. There's something intrinsically more painful about working long shifts every three days instead of four.

To top it off, this is Ramadan, so most of the day, my few morning calories (I'm usually only able to eat fruit and drink milk in the about stomach shrinkage) are gone before noon and I run on pure adrenaline in the evening. Alhamdulillah, I've been able to be a good intern the while fasting. It's been a good month.

So, last Sunday, I was on day call. I got in at 6:30am in time for group sign-out. Different from during the week, all of the patients are signed out to the interns and the seniors together. The seniors are the second and third years (oddly...I went to a medical school where second years were juniors). Sign out means you take the entire list with the important information about the patients and the night senior tells you what happened over night after giving a little one-liner about the patient to orient everyone. As the weekend intern on call, you pay attention to all of the patient's information, even though in the morning you're only rounding on 1/3 or 1/4 of the patients. The work is split between you, the night intern from the night before who is staying on to help with work rounds, the weekend rounder, who is a senior who stays through rounds and sometimes the day senior, who splits his or her time between the medicine service and the obstetrics service.

As the day call intern, you could round on anywhere between four and eight patients in the morning. Mercifully, our service hasn't capped, so weekend rounding usually means four or five patients.

After sign out, I peel off and work on progress notes for the morning. As a rule, anyone admitted the day before prior to midnight needs a progress note. Any other patients need a short addendum to their H&P or a small, separate note updated the plan. I tee up my notes, looking at notes left by specialists or attendings the day before and updating the plan accordingly. I also look at overnight events, vitals, new labs (sometimes not in yet, because they're drawn at 7am), and update the plan for patients.

That usually takes me 30 minutes to an hour, depending on how many patients I'm carrying and their complexity. My inpatient service has an open ICU, meaning we admit patients to the ICU and we follow them as they go to the step-down unit and back on the floor and everything in-between. It makes for great quality of care, but takes away the stress of having a dedicated ICU rotation as a family physician who doesn't plan on being a hospitalist.

After getting the notes together, I go and round on my patients. It's nice, because our electronic medical records include not only notes, but vitals and medication administration records, so unlike medical school, rounding doesn't mean looking at the EMR, finding the gray chart for any paper progress notes and nursing notes left, finding the green chart for the vitals and the slender blue charts for medications. I have no idea how I rounded on so many patients in that system while writing paper progress notes! Going to a program with a great EMR is great to improve efficiency.

So when I round on patients, I go in and see them, and that's it. It usually takes me 45 minutes to an hour to see four to six patients in the morning, usually because 1-2 of my patients do not speak English or have big families present (or both). Since we have patients who speak Asian languages, I do use an interpreter, and those visits usually take twice as long, also because not all of the specialists bother to use an interpreter (d'oh!) so sometimes I have to clean-up misunderstandings. When I see the patients, I ask them how things are going, update them on the plan for the day and for the coming days, ask if they have any questions, and then conduct a focused exam. Our program has a low intern cap (only 8!), and ICU patients count as two. Our service caps at 24. I trained at places where the list capped in the 30s, but they also had four interns on service and not just three. Since we have sub-interns usually, they help us carry part of the list.

After I see the patients, I update the note with my exam, any alterations in the plan based on my discussion with the patient, refresh any new labs and studies, and then print them out in preparation for work rounds. Work rounds are table rounds. Attendings come to our workroom and we go around the table, presenting our patients in five minutes or less.  For me, this is different from what I was used to in medical school, because usually for new patients, you gave the more full, seven minute H&P that was complete with HPI, PMH, etc. The most I give these days is an abbreviated HPI, relevant past medical history, pertinent positives in exam and then spend most of my time on my assessment and plan. One of the hospitals I did rotations in during third year had special rounds for the new patients. All old patients were presented in brief SOAP format.

So work rounds, almost all patients, even new ones, are presented in SOAP format. That's because, unlike my old system, we staff patients as they are admitted to the on-call physician. In the other system back in medical school, patients were staffed by the floor attending in the morning, thus requiring a fuller H&P.

Anyway. I'm still not past morning rounds, and I feel like I've written a lot! I'll keep going...

During rounds, the attendings may teach a few pearls or teach some topics, depending on how many patients they are carrying. We usually round with three or four attendings who represent the clinics where our patients are coming from. We round with the hospitalist for any ICU or step-down unit patients. We update our plans according to discussions during rounds and then make sure our notes are in and signed before around noon. At noon, we do teaching.

I work in a community hospital, but I come from a place where there was noon conference every day. In exchange for that type of system, my program has weekly teaching every Tuesday afternoon. When on inpatient, you only make that teaching once a month. As an intern, you're only required to make teaching 50% of the time. Topics repeat, so you're not left out, necessarily.

So, the Sunday on call started like any other weekend day on call. During the week, your senior also rounds on your patients (but doesn't write a note) and you meet before work rounds and go over the plan, but on the weekend, it's up to you.

After that, the night intern from the previous night gets to go home after his or her 7pm-11am shift, the weekend rounder also goes home, and all that is left is you and the day senior, who is also covering obstetrics, to cover the list, which may have anywhere from 14-24 patients, and take care of any admissions.

So that Sunday, two patients were being transferred from a neighboring hospital's emergency department and were to be admitted to our service. They came at the same time, unfortunately, and hit the floor at the same time. My senior, who can also help with admissions, asked if I would like to do both admissions or split them. Being the self-sufficient girly that I am, I said no, I'll do both admissions. That's my job as an intern, I feel. The seniors in my program provide a lot of support for interns for discharge paperwork. Though discharge summaries are the job of the intern, sometimes your seniors will help you, because they are due within 24 hours of discharge for patients discharging to home and upon discharge for patients discharging to facilities, and sometimes, your plate is too full as an intern to make those deadlines. On the weekends, seniors will sometimes do some of the admissions. I trained in systems where that was always, always the job of the intern, even if you get slammed. You peak in on the patient, you "skeletonize" orders, you see your sickest patients first and work backwards, H&P be damned!

I still feel the urge to operate like that, but this program splits the work and we'll even call in backup. I actually like this, because it improves patient safety.

Anyway, I was admitting my first patient, who required an interpreter. That patient was on the floor for almost an hour with skeletonized orders before the interpreter showed up. While I was in with the patient, I got a page that the second patient was on the floor and needed orders. That was fine, I figured. I'd be done with this patient soon enough.

Then, in the middle of my admission, I get a page that a patient that I'm cross-covering for wants to leave AMA, against medical advice, and to come talk to them. I had a patient leave AMA earlier, frustratingly, only to return a few hours later to the emergency department. But I was in the middle of the admission of this patient. I would respond to that page within the next five minutes, but I wanted to tie things up. Next thing I know, I hear a violence code called over the loudspeakers and get a second page that the violence code was called on my cross-cover patient, and I needed to be there, now!

I explain the situation to the interpreter, tell her I'll be back in 10-15 minutes, and run to the step-down unit where security guards are already surrounding the area. By the time I get there, the patient is still in bed but belligerent. I talk them down and convince them to stay. Somewhere in there, I page my senior's personal pager through my phone and he comes running in. I stay for about 15 or 20 minutes more to ensure that the situation deescalates before I return to admitting my patient with the interpreter. Because of the interruption, though, I'm now behind admitting the second patient, and my senior skeletonizes orders for her and looks in on her. Within the hour, I admit both patients and work on their H&P's. My senior in the meantime is getting slammed in obstetrics and I have my wish, to be on my own admitting patients.

I staff both patients by about 6pm, meaning I give an over-the-phone H&P to the admitting attendings, who make any updates to my assessment and plan. I tidy up the rest of the note and update our sign-out, which is a word document that lets the night team know what is left to be done for patients and any cross-cover issues to know about (like the cross-cover patient with the tendency towards violence and leaving AMA).

Time flies when you're super busy, and before we know it, it's time to sign out patients. The senior lets me do sign out for my own patients and then they usually sign out the rest. In the mornings on weekdays, the night intern signs out to the day intern who follows the patient, and the night senior signs out to the day seniors and signs out obstetrics to the maternal-child health resident. And then I tidy up anything undone and I'm kicked out by 8pm so I don't violate duty hours.

This past week, the week that began with that Sunday, I worked for 83 hours. The cap is 80. I technically do not violate duty hours because I have to work less than 80 hours on average for the entire rotation. This is the only week I'll violate hours. On nights, you work 12 hour shifts and you only do six nights in a row, so I'll probably work 76 hours that week (including the one night where I stay on until 11am). I've fasted Ramadan while working nights's just odd, because you only eat during a small portion of the night. You realize just how short the night is in the summer when you do that. that is a standard day in the life of a family medicine intern on service. It was a pretty tranquil day with just two admissions. My co-intern got slammed on Friday with, like, four admissions between noon and six. I just did call on Saturday and admitted no one, but discharged a bunch of patients. Diuresing the list, if you will. The days vary, but that's good, or else you'd be constantly tired...

I just slept for about 10 hours last night, from 9:30pm to 8am, waking for salat and suhoor. I need to also nap during the day prior to my shift, insha'Allah, although, unlike the rest of the rotation, I'll be able to drink caffeine to keep me awake!

Anyway, I'm here, still in bed, lounging around before I go into the hospital at 7:30pm to begin my night.

Let me know if anyone has any other questions for me! This was a long post, sorry, but I haven't written something not a discharge summary in a while!

Thursday, August 2, 2012

Almost Perfect

As salaam alaikum,

When I started practicing Islam, I was a perfectionist. There is nothing in Islam that would discourage this. I came to this faith as a nominal Muslim teenager who knew a few rituals, salat and a few heavily-accented (as in English accent) Arabic utterances, not nearly enough to convince anyone I was Muslim. So I played major catchup.

But I digress. I came into practice of this faith because I believed that it was the straight way (and I still do), and I wanted to follow that way. This was the way for me to be almost perfect, almost completely perfect as God commands us by avoiding the major sins and seeking daily (five time daily and once annually, through Ramadan) forgiveness for all of my faults. My sins would be as good as erased every Ramadan, and anyway, they'd be tiny ones because, having been shown the straight way, how could I err?

Wouldn't I be a disbeliever upon erring?

I came into the practice of this religion without properly knowing that the straight way is not singular or self-evident in terms of steps one should take to achieve that almost perfection I aspired to.

I keep making mistakes. Sometimes I make them multiple times. I tried so hard for almost perfect but I never was.

So where does this leave me? If I decide to no longer try being almost perfect, then where does that leave me?