Remember the feeling on your first day of school? Each year, the month of August was filled with anticipation, shopping, excitement, and anxiety. As children we hoped to find friends in our new classes, in college we dreaded heavy workloads, and in med school we just put our heads down and hoped for the best.

Today I feel a similar anxiety, and a new emotion, fear. In the past month I have crossed the country from coast-to-coast, found an apartment, graduated from medical school, and packed up my entire life in the back of 2002 Pathfinder (save for a set of golf-clubs and a crock-pot that just didn't quite fit) to open a new chapter in a new city with new people... New. New. New.

And amidst all the excitement of "new" is the growing fear of "new." After four years of undergraduate and four years of medical school, I, along with three other interns at Cedars-Sinai and thousands of new doctors across the country, am about to embark on the journey we have worked so hard for and yet I am filled with dread.

This next first day is just one of many to come. And each one, from here on out, asks the questions, am I good enough? am I ready? At some point you have to learn to trust the system-- with real lives at stake, medical schools would not graduate us and hospitals would not hire us, if it compromised a life. Yet, despite this knowledge, there is an inner fear that grips our hearts and twists our stomachs. Despite what our parents and friends may think, and the diploma on the wall may suggest, we understand that our education is really just beginning; a fact that fuels our fears and anxieties.

Each day, I wake up and pinch myself. As the official start date draws nearer, the anxiety grows, the fear gets a little stronger, and it gets more and more real. The pinch hurts. This is not a dream. Or is it just my dream?

The question never seemed so appropriate, nor so poignant as it did following the Boston Marathon bombings earlier this week. On his show, Dan Patrick (as well as many others) repeatedly, and almost rhetorically, asked this question. While many of us hope that our answer would be "to help others," the truth is that we don't know. But for the runners and fans on Monday who faced that very question, hypotheticals removed, there were many who answered heroically.

Stick around a race long enough and you'll begin to hear tales of the wall. It is the stage of endurance races where you reach your physiologic limit. Most common in triathlons, marathons, and long cycling events, "hitting the wall" (or "bonking") describes a state of altered consciousness. Athletes describe hallucinations, confusion, dizziness, and utter loss of control to the point of an out of body experience as they push to the end of a race. The physiology is incompletely understood and has been attributed to energy depletion, dehydration, and nervous system dysfunction. The effects are disastrous as we see runners wobble, stumble, and struggle through until they fall or finish.

Mondays attacks were an extracorporeal wall. And yet they seemed to tear down the very wall they represented. Out of the smoke, amidst the chaos, we saw runners go beyond the marathon they were racing to give blood and help their fellow competitors. For those who were stopped short of finishing the 26.2 mile course, they added extra miles to the nearest hospital or to the reunion area where they found family and friends.  

The thing about running is that for 99-plus percent of us, it is not a livelihood but a lifestyle. We run for fun and for fitness, for peace, serenity, and camaraderie. And in so doing, we form special bonds- a silent nod to the man we pass every day on our favorite loop or the collective energy as we gather en masse at the start of a race. We are out there for the love of sport and the love of life. The tragedy of the Boston Marathon will endure in infamy, but already we have bonded together and those runners who continued on to donate blood showed their heroism and dedication to this family. Should I ever be asked the question of which way to run, I hope the motto "Boston Strong" pushes me in the right direction. 

I’ve never been one with much affection for cold or inclement weather and as such, between November and April, most of my training is done on the treadmill. While many people lament the monotony and unchanging scenery that treadmill running brings, I take the time to lose myself in podcasts. Recently, during a set of race-pace intervals, I listened to a podcast that featured an interview with Bart Yasso. Yasso is a former champion marathoner, lyme disease survivor, and the chief running officer for Runner’s World magazine with a popular workout named after him, the Yasso 800’s. As someone who travels around the world to race, teach, and meet people, he has the self-proclaimed best job  in the world. During the interview, Yasso comments that “winning isn’t the payoff in , but rather the reward is living the lifestyle and embracing the journey. It’s not only about finishing, it is about moving forward.” 
 
Even on the treadmill, this comment gave me pause. I am a competitive person and always have been. I have a strong internal drive that permeates every aspect of my life. From the hospital and OR to the gym and road, I push myself to the point of breaking because I’ve never known another way. Over the years I’ve developed a mental toughness that pulls me out of bed at 4 am  to run before heading to work and keeps me up at night, reading papers and textbooks to better care for my patients. Like the treadmill, it sometimes makes my life so regimented that I simply step through the days and forget to enjoy the moment I’m in.

As I move into the next stage as a surgical resident, the responsibilities at the hospital will increase and I will feel myself pulled in more directions than ever before. Mentally and physically, I will be pushed to the limit at work. And yet, this makes those 4-am runs ever more important. They provide moments for reflection so that I may, as Yasso said, embrace the journey.

I will probably never win a race outright. And with my increasing time constraints, I may never be a faster or more competitive runner than I am right now. Still, I will need to remind myself that fitness and health are passions of mine and running is as much of my identity as becoming a surgeon. I must learn to embrace the run for the sake of lifestyle, to not become discouraged if my times drop, and to make sure that I am always following my passions. Only then, when I reach the age of Bart Yasso, can I also have the greatest job in the world.

The envelope felt heavy in my hands, heavier than a few pieces of paper should. The name on front was printed in crisp black ink and while it was my own, it looked foreign. It seemed only days ago that I first slipped into a short, white coat. I was young and eager, bright-eyed and bushy-tailed with 170 other new physicians in training. Over four years of medical school, our aspirations lead us down a multitude of diverging paths, yet today our paths merged once again for a champagne toast and the opening of these envelopes. Inside, the beginnings to our futures were laid out in a few lines, new paths for each of us to follow. My fingers stuck to the edges, unwilling to slide under the seal and make real the inevitable. I could feel my heart beating, a sensation we learned about years ago; I forget the mechanism now. Around me, the sounds of excitement began to grow, confining me even more. What name lay inside, what did I hope for? In moments I would know, and then what? My mind raced ahead to all of the things that will happen in the next two weeks- signing paperwork, fixing financials, securing housing; packing up the life I had built over four years in Ann Arbor and starting anew.

A squeeze on my thigh brought me back to reality and I looked past the envelope to the barren left hand that was turning white with tension. Abagail. After six years, that finger deserved to be adorned. As a career-driven person, I could never back her into a corner with an engagement. But she has been there, through the highest highs and lowest lows of medical school and life. Our tale is one I don’t want to end. I am reminded that the contents of this envelope affect her life every bit as much as my own. I wished we could stop time, enjoy life together without the anxiety and tension that has been building a wall between us. Hoping for the best, we prepared for the worst. I looked up and our eyes met, her soft smile nudged me along, as if to say, "there’s nothing left now, just do it."

More people have discovered their future. They begin to rise from their chairs, family members clapping, and hug or high-five each other. Laughter abound. My hands begin to wake up and feel the sharp corners of the envelope. I begin to slide my finger under the flap and peel away the glue. I cannot help but wonder if I made the right decision, if I chose the best career path, if my rank order was correct. Would I be truly happy with whatever name was written on the piece of paper I was about to read? This was supposed to be the most exciting day of medical school, but it left my stomach in knots. I quickly took a sip of champagne, liquid courage? My hand returned to the envelope and began to rip across the top. I could not be the only one feeling this kind of pressure. I half-admired my classmates who chose to do this in front of everyone and half-wondered if they secretly knew their destination. They all seemed happy to place their pins on the map. Where was my pin going to go?

I pulled out the piece of paper. My hands had new life, though they seemed not my own. I could not control them now. I wanted to stop them, to keep them from revealing my future. I tried to avert my eyes but they were stuck on the unfolding edges. “Dear Justin Steggerda.” There was my name again. This was not a mistake, just a few more lines and I would know. “Congratulations.” My breath caught in my throat. I closed my eyes, the next line carried my future. There is no stopping now. I forced my eyes back open. I read on. I smiled. My future was here.