For some families, events like Tuskegee are not something learned in school; they are something discussed at home. It becomes part of a broader narrative about caution around medical authority. Even for patients who do not explicitly reference it, the awareness that medicine has caused harm in the past can inform a more guarded posture. It is not only about one historical event. Ongoing disparities in maternal mortality, pain management and access to specialty care reinforce the perception that the system does not treat everyone equally. When patients hesitate, that hesitation may reflect not a rejection of science, but an assessment, based on history and present experience, of how much trust feels reasonable.
As a third-year medical student, I am stepping into a profession with both extraordinary achievements and undeniable harm in its history. Recognizing that complexity has changed how I respond when a patient says no. Not all hesitancy stems from history. Sometimes it grows from much smaller moments.
On a family medicine rotation, I met a woman with uncontrolled hypertension who had stopped taking her medication. When the resident asked why, she said,“ I called about side effects, and no one ever called me back.” That was it: no dramatic event, no conspiracy, just silence.
But to her, that silence meant her concerns did not matter. And if her concerns did not matter, why should she trust the next recommendation?
I have started to notice how fragile trust can be: whether we sit down or remain standing, or whether we make eye contact or type while patients speak. Do we pause long enough for them to finish a thought? These details feel small to us. They are not small to patients.
Before clinical year, I sometimes interpreted hesitancy as resistance. Now I see it more often as fear. Behavioral science teaches that people weigh potential harm more heavily than potential benefit. For a patient who once felt dizzy or nauseated after a medication change, that experience can loom larger than any survival curve we present. I saw this play out with a man admitted for heart failure. He resisted starting a beta blocker because a previous medication adjustment had left him feeling weak and unsteady. The team initially responded with data: mortality reductions, hospitalization rates. The numbers were compelling.
But what shifted the conversation was something simpler. The attending said,“ It sounds like last time you felt worse, and that scared you.” The patient nodded. Only after that acknowledgment did the discussion move forward. I am beginning to see that hesitancy is often an expression of vulnerability. Patients are telling us, in their own way,“ I don’ t want to be harmed.”
As a student, I do not write final orders or make definitive plans. But I am learning how trust is rebuilt.
I have seen the power of asking open-ended questions:“ What worries you about this?” and“ What has your experience been before?” I have seen how validating a concern, without endorsing misinformation, can soften defensiveness. Saying,“ I can understand why that would make you cautious,” does not weaken authority. It strengthens connection.
Clear, honest communication matters. Framing risks in concrete terms, i. e.,“ Out of 100 people like you …,” makes information feel less abstract. Being transparent about possible side effects and offering a clear follow-up plan demonstrates accountability.
Shared decision-making has also stood out to me. When attendings present options and invite patients into the decision, the dynamic changes. The plan becomes collaborative rather than imposed.
Perhaps most importantly, I have seen how follow-up builds trust: a phone call after starting a medication; a scheduled check-in; continuity with the same provider. These gestures communicate commitment. Trust is rarely built in a single dramatic moment. It accumulates through consistency.
Third year has forced me to confront my own assumptions. I entered rotations believing that good evidence would naturally lead to good decisions. I still believe deeply in evidence-based medicine, but I now understand that evidence alone is not enough. Patients need to feel safe. When someone hesitates, I try to remind myself that they are not opposing me. They are protecting themselves in the best way they know how.
I am still learning. I still feel uncertain in many rooms. But I am beginning to appreciate that medicine is not only about treating disease, it is about tending to relationships. Medical hesitancy is not a problem to solve quickly. It is a signal that trust needs attention, and rebuilding trust requires time, humility and genuine presence.
If I carry anything forward from this year, I hope it is this: when a patient says“ No,” it is not the end of the conversation. It is the beginning of understanding why.
And sometimes, understanding is the first real step toward healing.
Emma Heironimus is a fourth-year medical student at the University of Louisville School of Medicine.
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