Lessons From Huck Finn: Reliable Narration in Medicine

Nate Cameron, M1, Class of 2023

“and he told the truth, mainly. There was things which he stretched, but mainly he told the truth. That is nothing. I never seen anybody but lied one time or another…”

Adventures of Huckleberry Finn, by Mark Twain

The first time I discovered books could lie to me was the summer before seventh grade, laboring through Mark Twain’s Adventures of Huckleberry Finn. Twain’s novel opens in an almost confessional tone, explaining to me— the dedicated reader— that another novel couldn’t be trusted to fully tell the truth. In this way, I stumbled upon what literary people call “unreliable narrators.” The experience was one of my first storytelling revelations— characters possessed the capacity to withhold, modify, or even forget information in the stories I was reading. Huck Finn planted seeds of awareness, if not distrust, for future narrators I would encounter.

In novels, narrators can be deemed “unreliable” for a variety of reasons. In the case of Huck Finn, his youth and precocious personality imbue his storytelling with inherent exaggeration and misunderstanding, whether intentional or not. Others, like Satan in John Milton’s Paradise Lost, filter their words out of self-interest, so their statements can’t be taken at face value. However, people in the stories we read are simply reflecting “real life.” As a result, information is missed in communication, falsified, or simply forgotten. The characters we read about in books are intended to behave like us — that is, prone to error.

My initial frustration with unreliable narrators molded with intrigue as I continued studying literature in college. As I struggled to look beyond what was explicitly stated, my senses sharpened to ambiguity and nuance. Again, people telling stories is reflective of the way we think and speak in normal life; there are things we purposefully for- get, as well as parts of our day we like to exaggerate, and still others we choose to diminish.

To my surprise, I observed the process of narration most prominently in physician- patient interactions rather than in the pages of a book. Watching medical interviews, I noticed how the physician and the patient unraveled a narrative, guiding each other in its construction. Phrases from the doctor like “catch me up to speed” or “start at the beginning” invariably drew a story from the patient. Indeed, storytelling seems inseparable from medicine. But who gets to tell the story? How can physicians become reliable narrators for their patients’ lived experience?

Unfortunately, the same ailments that give way to unreliable narration in literature can be found in patient care. Patients may withhold information, either knowingly or on accident. Likewise, physicians might struggle to articulate their reasoning for a certain medical or surgical procedure. What is more, providers may lack the ability or time to listen adequately. The resulting account — often in the form of a post-encounter note — will be unreliable. The patient’s story is not told in its fullness.

This can be mitigated by striving to preserve the patient perspective. To this end, I realized why the “chief complaint” should be strictly written in the patient’s own words. Regardless of physician opinion, the patient outlook remains protected, and the physician is relegated to a second person viewpoint. Narrative reliability, in this case, is dependent upon a dual perspective. The inclusion of two perspectives, or co-narrators, allows for a more rich and full account. So too, space is created for the subtleties and contradictions embedded within human conversation.

As I continue to practice documentation and patient interviews, the storytellers from my time as an undergraduate linger in my mind. With the acknowledgement that I will be entrusted to narrate my future patients’ stories in the form of encounter notes and treatment plans, I’ll look to borrow some insight from Huck Finn — the task of telling our story is a difficult one. The task of telling another’s is harder still. However, it seems the occasional exaggeration or downplay of information is the product of our individual experience. So, even as my studies in literature now give way to biochemistry and immunology, I look forward to having the challenge of storytelling around for the rest of my career.