Listening past the barriers 

By Siyuan Wang, MD, PhD, Johns Hopkins Observership Program, with Sonal Gandhi, MD, Johns Hopkins Medicine 

During my clinical observership at Johns Hopkins, I found myself often reflecting deeply on my connection with patients who are veterans, something that feels both personal and instinctive because of my background. I grew up in a military medical family in China, living within military communities. My grandparents and parents were all military doctors, who cared for soldiers and veterans not just with clinical skills, but with cultural understanding. In China, military hospitals prioritize care for active-duty soldiers and veterans but also serve civilians without barriers. Likewise, veterans can walk into any civilian facility without referrals or special permission. Because of this structure, both military and civilian clinicians develop comfort and fluency with a wide spectrum of illnesses across all groups. 

After coming to the U.S., I encountered a healthcare system that places veterans in a separate VA program, which is comprehensive in many ways, offering financial support and tailored programs. As a result, civilian clinicians may not see veteran patients frequently. Because of this divide, civilian healthcare professionals may be unfamiliar with the common conditions of veterans, how they present, or the deeper context that shapes their engagement with care. By the time a veteran navigates through the obstacles and sits across from us, they may be met by someone who doesn’t speak their “language,” either clinically or emotionally. Without access to a veteran’s records and disability evaluations, and sometimes without shared terminology, clinicians may find building patient trust challenging. 

I’ve thought a lot about two veteran patients I met at Johns Hopkins. One was a patient with advanced heart failure who came in with worsening shortness of breath and severe volume overload. Once stabilized, we discussed long-term options, including advanced therapies and possibly transplant. He listened quietly and then answered very plainly: “I wouldn’t qualify. I live in my car. Got no one left.” There was no visible distress or hesitation. He said it as if it didn’t matter to him. 

The other patient had even more complex medical issues. From her chart, I expected someone in need of coordinated, multi-specialty care, but at the bedside, she was emotionally distant, answering with clipped sentences. “My health crashed after deployment,” she said. She showed no interest in long-term planning or prognosis, apart from being discharged. Any further inquiry was met with the same answer: “It’s in my records.” When transplant was mentioned, she replied flatly: “They won’t approve me. I got leaky heart valves and lymphoma. I’ll just live like this until it’s time to die.”  

For someone familiar with military values, both patients reminded me how mental toughness, emotional control, acceptance of the uncontrollable, and self-reliance deeply influence veterans’ approach to care. Trained to endure hardship, follow command, and conceal vulnerability, many of them internalize these values as part of their identity. However, in civilian society, this may be misinterpreted as disengagement, apathy, or “noncompliance.” Veterans may also mistrust civilian healthcare professionals, viewing them as unfamiliar with their culture or experiences. Alongside PTSD, traumatic brain injury, depression, and substance use disorder, sometimes they also carry moral or existential burdens that influence medical decisions, engagement with care, and trust in systems. Fragmented care between VA and non-VA settings only deepens these gaps. 

Below are a few small but meaningful communication habits I observed when my parents cared for similar patients, shared in the hope that they might help build trust and deepen connections, even just a little bit. 

1. Ask questions about their service. 

Some examples include, “What branch did you serve in?” “What was your role?” and “When did you serve?” Listen closely, even if the answer is brief. This is often the first step toward trust and sometimes can reveal important history that informs trauma, injury patterns, mental health, and resource eligibility. 

2. Acknowledge their contributions and sacrifices, then move on. 

Say: “Thank you for your service” sincerely and briefly. Some veterans appreciate the gesture, while others remain wary of it. The point is to see them rather than elevate them. 

3. Lower your voice.  

Many veterans often retain the habit of responding to authority with automatic obedience, shaped by years of military training. A healthcare professional’s tone of voice can unintentionally trigger this response, leading them to follow perceived “orders” rather than engage in open discussion. This can shut down the shared decision-making process before it even begins. 

4. Use conversational language to explore mental health.  

This matters especially when caring for veterans, not just because mental health concerns are so common, but because the traits they carry with pride, such as resilience, endurance, emotional control, can lead them to actively filter out anything that feels like weakness. Conversational language and thoughtfully framed questions can allow us to explore mental health without triggering defensiveness or the sense of being evaluated. For example, questions such as “Have you gotten back into any of your old hobbies since coming home?” can invite more openness than direct screening. These subtle shifts can help bypass internal barriers and open topics that might otherwise stay sealed.  

5. Understand that silence sometimes is a way veterans communicate.  

Because resilience and toughness are deeply integrated into military culture, veterans often respond with silence to questions that feel like they’re asking them to “complain” or show weakness. That silence can mask both emotional struggles and physical suffering. In healthcare, this can be easily misinterpreted as disengagement. What veterans may need is more time, gentle encouragement, and a reframing of conversation to help our veteran patients understand that sharing what they’re going through isn’t complaining; it’s helping us to care for them. That shift may turn what once felt like vulnerability into teamwork. In this way, we can correctly interpret the minimal communication or silence of veteran patients. 

These are starting points to meet veterans with more patience and understanding, and to see them as people shaped by service. Sometimes, this is where true healing begins. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.