When an Unexpected Next Step is the Right One

When I began telling people I was considering becoming the Founding Program Director of a new family medicine residency in rural Eastern Washington, the responses were not exactly subtle.

“Are you nuts?”

“Do you need me to say WTF, Tonya?!”

And, perhaps most thoughtfully:

“This doesn’t seem aligned with what I know about you.”

Only two people outside those directly involved in developing the program immediately said, “Do it. You’re perfect for it.”

The others were not questioning the hospital system, the sponsoring institution, or even whether I could do the job. They were questioning whether the role fit the life and body of work I had deliberately built.

Honestly, I understood their concern.

At first glance, accepting an institutional leadership role while continuing to coach, teach, speak, and develop faculty—right when my husband is retiring and we are moving—might not seem particularly aligned or even like great timing. Starting a residency program from the ground up is not known for being a relaxing little side project.

Two of the wisest and most experienced people I consulted offered cautious support. They did not tell me whether to take the position. They helped me think through what would need to be true for me to say yes: clear boundaries around the role, continued space for the other work that matters to me, and clarity about the scope of the founding role and how leadership would evolve as the program became established.

Their caution was not opposition. It was discernment. It helped me recognize the conditions under which this role really could fit and pushed me to look more deeply at why I felt drawn to it in the first place.

Sometimes the right next step may look completely wrong until we recognize our throughline.

In William Stafford’s poem “The Way It Is,” he writes:

There is a thread you follow.
It goes among the things that change, but it doesn’t change.
People wonder about what you’re pursuing…

In her STFM presidential address and essay “Three Poems, One Challenge, and a Promise,” Renee Crichlow, MD, calls Stafford’s thread “purpose” and connects it to promise and duty.

I began to see how deeply the work itself aligned with the thread running through nearly everything I have done.

I care about access to high-quality primary care for everyone, particularly people who are vulnerable, marginalized, geographically isolated, underinsured, or otherwise face barriers to receiving it. That has been part of my career from medical school on.

Access requires a strong physician workforce pipeline. That means training excellent physicians, developing the faculty who teach them, and creating teams, systems, and cultures that allow people to keep doing good work without being steadily worn down by it.

My coaching, teaching, faculty development, team development, and program-building have all been different ways of strengthening the people and systems that make excellent primary care possible.

Building a residency does not take me away from that work.

It actually brings all the pieces together.

Dr. Crichlow also quoted Pirkei Avot:

You are not obligated to complete the work, but neither are you free to abandon it.

That line has stayed with me. It spurred me to continue my clinical work even after I had given up my continuity panel for coaching in residency programs. It led me to seriously consider one leadership opportunity, take on the work of building Alaska’s statewide Graduate Medical Education Council, and eventually say yes to this new role.

So, it is official.

This past Monday, I began my role as the Founding Program Director for a new family medicine residency at Samaritan Healthcare in Moses Lake, Washington, with Washington State University serving as our sponsoring institution.

I was drawn to Samaritan first by its people.

During my site visit, I wandered into its beautiful new 45-bed hospital as an unknown person clearly trying to figure out where I was going. The people I encountered did not know who I was or why I was there. They simply noticed, warmly welcomed me, and helped.

That same grounded warmth extended to the executive team. They are down-to-earth, straight-shooting people who care deeply about their community and understand what building a residency could mean for the region. I see them as proactive, forward-looking leaders who are investing in building a new program at a time when many others are cutting spots.

I also have the great fortune of beginning this work alongside Trinity Turner, BS, C-TAGME, our GME Director – the role known as Program Administrator in GME language. She brings deep family medicine GME program administrator and experience, including managing the complexities of a large residency program, federal funding, accreditation, scheduling, and the countless operational details required to turn an idea into an actual residency.

More importantly, she is someone with whom I can build, problem-solve, rumble when needed, and still enjoy the work. We have already started talking about how we will work together.

Our partnership with WSU gives the program the strength and academic grounding of a university sponsoring institution. The university brings a distinctive approach to community-based medical education and an impressive record of retaining 88% of graduates from its sponsored primary care residency programs in Washington. Its Designated Institutional Official and I have already begun building a strong working relationship. We share a commitment to building the program thoughtfully, meeting the rigor required of residency training, and keeping the needs of the region at the center. That work is supported by a GME office with more than 60 years of combined experience.

And then there is the remarkable support of being part of the top-notch WWAMI Family Medicine Residency Network. As part of that, we have Dave Evans, MD who meets regularly with new program directors.

And then there is the remarkable support that comes with being part of the top-notch WWAMI Family Medicine Residency Network. Through the network, we have Dave Evans, MD, who meets regularly with new program directors.

Russell Maier, MD, is our official technical assistance advisor through the Rural Residency Planning and Development grant, in addition to the other supporting roles he plays within the network. Finally, Samaritan has partnered with Residency Program Solutions to bring Alan Douglass, MD, on as our official consultant.

If you recognize those names, you already know I hit the rural GME jackpot. Seriously, you can’t dream this stuff up.

We have a great deal to build before residents arrive (hopefully July 2029): clinical and residency space retrofit, community partnerships, policies, clinical experiences, curriculum, faculty relationships, systems, our own culture, and eventually an application for accreditation.

That is precisely what drew me in.

We have an opportunity to ask from the beginning what rigorous, relational, and increasingly sustainable family medicine training could look like. We can be intentional about the conditions that make that possible: faculty depth and support, time for teaching and the work surrounding patient care, strong faculty-resident relationships, true team-based care, and a culture in which people can learn, contribute, reflect, and grow.

We will not solve every challenge facing primary care or medical education. But we can build something thoughtful together and invite future faculty and residents who care about these questions to help shape it. (And if you know an experienced family medicine educator who might be energized by moving to Eastern Washington to help us build something new, please send them my way.)

On day two, I had the pleasure of presenting all things graduate medical education and family medicine residency to the regional governance boards representing neighboring critical access hospitals and a federally qualified health center.

So, you know, I’m just “easing in” here. No pressure. 😂

In case you were wondering, my coaching and faculty development work will continue. 

From the outside, this may have looked like an unexpected turn.

From where I stand now, following the thread, it looks remarkably like the work I have been pursuing all along.

Reflection:

·       Is there an opportunity that looks wrong from the outside but may align with your deeper purpose?

·       How do you know when to trust your gut when everyone else thinks you’ve lost your mind?

·       What would need to be true for an unexpected opportunity to fit your life?