Beyond the Hard No: Finding Footholds for Trust
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October 27, 2026
I left the 2026 ABIM Foundation Forum in Stowe with many pages of notes. Some contained ideas I wanted to remember. Others contained questions I still do not have answers to. One phrase, in particular, has stayed with me: accepting the hard no.
In medicine, we frequently encounter the hard no. A patient declines a vaccine. Another refuses a medication we believe could change the course of their disease. A community remains skeptical of a healthcare institution despite repeated attempts at engagement. We explain the evidence, discuss the risks and benefits, answer questions, and sometimes leave the encounter wondering: What more could I have said? But one of the conversations in Stowe made me reconsider the question itself.
During one of our table discussions, a distinguished gastroenterologist shared the story of a patient with Crohn’s disease who had failed several treatments and needed biologic therapy. She refused. Her mother had died from a complication she associated with biologic treatment. For her, this was not an abstract discussion about probabilities, guidelines, or relative risk. Her understanding of the treatment had been shaped by loss.
The physician continued caring for her. He discussed the treatment with her again. She still said no. He continued seeing her, and the conversation continued over the years. It took approximately five years before she eventually agreed to biologic therapy. I have thought about that story many times since Stowe.
The wall behind the “no”
It is tempting to hear a patient’s “no” as a response to the recommendation immediately in front of us. But sometimes we are entering a conversation that began long before we walked into the room.
Mistrust has a history.
For some people, it is rooted in a painful encounter with a clinician. For others, it comes from experiences with healthcare institutions or from the experiences of parents and grandparents. Some mistrust is reinforced by what people have witnessed in their communities. And some may arise from stories, perceptions, or assumptions rather than direct encounters. From the clinician’s perspective, we may be tempted to distinguish what objectively happened from what someone believes happened. But when we are trying to understand why someone does not trust us, that distinction may matter less than we think. A perception that has shaped someone’s understanding of healthcare can influence a decision as powerfully as a personal experience.
By the time we encounter some patients, we are not standing before a newly constructed wall. We may be standing before one that has been built, repaired, and reinforced over generations. One conversation is unlikely to bring it down. That realization changed what accepting the hard no means to me.
It does not mean abandoning the patient. Nor does it mean repeating the same argument until the patient eventually surrenders. It means having enough respect for the person to recognize the “no” that exists today while having enough commitment to the relationship to return tomorrow. The gastroenterologist’s story was powerful not simply because his patient eventually accepted the treatment. It was powerful because he stayed. He remained her physician even though she disagreed with him. There is something profound about that kind of presence: I see you. I hear you. I may disagree with this decision, but I am still here.
Perhaps trust is sometimes built exactly that slowly. The goal may not always be to knock down the wall. Some walls have been built and reinforced over generations, and expecting a single clinician, or even a healthcare system, to dismantle them may be unrealistic. Instead, each encounter can create a foothold of trust: being present, listening without judgment, acknowledging past failures, keeping a promise, returning after a difficult conversation. One foothold may seem insignificant, but over time, these moments can offer a way to reach the person on the other side.
Patients do not come to us alone
Another idea from Stowe complicated this further: we cannot fully understand patients when we separate them from the communities and generations that shaped them. Every patient enters the examination room carrying more than a medical history. They bring family experiences, community narratives, cultural expectations, economic realities, memories of previous encounters with healthcare, and ideas about whom they can trust.
If mistrust can be built and reinforced within communities, then trust must also be cultivated within them. That requires more than knowing about a community or caring for its members one patient at a time. It requires presence: showing up, listening, participating, and allowing people to see that we are invested in the places and people we serve.
There is a difference between being a doctor who works in a community and being the doctor people recognize as part of their community. The latter does not require that we share the same hometown, background, or history. It means being present enough to say, through our actions: I see you. I hear you. I am here with you, and your community’s health matters to me too.
That presence must also extend beyond the moments when healthcare needs something from the community. Community engagement cannot simply appear when vaccination rates fall, screening numbers decline, or an institution needs participation in a new initiative. Relationships built only when healthcare systems need communities are unlikely to feel like relationships at all. Being present means listening before proposing solutions and acknowledging the expertise communities already possess about their own lives.
Panagis Galiatsatos explores this approach further in Medicine for the Greater Good, which offers a thoughtful perspective on what it means for healthcare professionals to engage with, learn from, and become genuinely invested in the communities they serve.
Perhaps that sense of belonging is itself another foothold for trust. And sometimes, being part of a community also requires the humility to recognize that the physician may not be the most effective person to deliver the message.
Sometimes the messenger matters as much as the message
Medical training places enormous emphasis on expertise. We learn how to interpret evidence and translate it into recommendations for our patients. Because the recommendation is scientifically sound, it is easy to assume that communicating it clearly should be enough.
But a good message delivered by someone who is not trusted may travel nowhere.
There may already be people within a community who have spent years building the relationships that healthcare professionals are only beginning to build: faith leaders, teachers, community organizers, local advocates, barbers, coaches, patients, and others whose voices carry credibility. Partnering with them does not diminish the physician’s expertise. It recognizes another form of expertise. Sometimes our responsibility is to deliver the message. At other times, our responsibility may be to equip and support someone whom the community already trusts to deliver it. That requires a certain humility from medicine. We do not always have to be the messenger.
One of the observations from the Forum that stayed with me was that building trust requires finding something on which we can genuinely agree. Another was more uncomfortable: we must sometimes be willing to call out our own tribe.
That matters.
If healthcare professionals defend healthcare reflexively, including when our institutions have failed people, why should communities believe us when we ask them to trust those institutions again? Acknowledging where medicine has fallen short is not an attack on the profession. It can be evidence that our allegiance to the people we serve is greater than our instinct to protect the institutions to which we belong.
From individual encounters to institutional change
The conversations in Stowe also left me thinking about what these principles would look like if we moved them beyond individual clinicians. If communities matter to health, then community engagement should not exist at the margins of healthcare institutions. It should be part of their structure.
What if hospitals routinely met with the communities they serve, not only when there is a crisis, but through regular town halls, listening sessions, and focused conversations about community health priorities? What if community members had meaningful representation in hospital governance and helped shape decisions that ultimately affected them? What if we treated the ability to build and sustain trusting relationships as something worth recognizing and rewarding among healthcare professionals, just as we do for other dimensions of healthcare quality? And what if partnership with people outside medicine became something we intentionally taught healthcare professionals rather than something they discovered by accident?
These are not complete solutions. But they represent a different starting point: instead of asking communities to come into healthcare on our terms, healthcare can become more willing to meet communities on theirs.
