Dr Win Huang’s Clinical Reflections | If Treatment Works, Does It Mean the Diagnosis and Treatment Were Correct?
By Dr Win Huang, PhD (Chinese Medicine & Acupuncture)
Some time ago, I watched a professor from a major pain medicine department in China discussing lower back pain.
He considered the quadratus lumborum to be a very common and important source of muscular lower back pain. Much of his examination, diagnosis and treatment therefore focused on this muscle.
It made me think.
I have treated many patients with lower back pain over several decades of clinical practice. Yet cases in which I believe an isolated quadratus lumborum problem is the main source of the patient’s symptoms are relatively uncommon—perhaps only a few each year.
Why can two clinicians looking at the same problem see it so differently?
I have thought about this question for a long time.
Every Clinician Has a Comfort Zone
Clinicians from different professional backgrounds naturally approach patients through the methods they know best.
A massage therapist may think about manual treatment. An acupuncturist thinks about acupuncture. A physiotherapist may focus on muscles, movement and rehabilitation. A chiropractor may pay more attention to the spine and joints. Pain specialists are familiar with medication, injections and nerve blocks. Surgeons, naturally, are most familiar with surgery.
There is nothing inherently wrong with this. Every clinician develops areas of knowledge, examination methods, diagnostic language and treatments in which they have the greatest confidence.
This becomes our comfort zone, but it can also become our boundary.
If a clinician believes the quadratus lumborum is an important cause of back pain, they may examine it more frequently. They find tenderness or tension, treat the area, and the patient improves.
A natural conclusion follows: my diagnosis was correct, my treatment worked, and the quadratus lumborum was the main problem.
As more successful cases accumulate, that clinical framework becomes increasingly convincing.
If Treatment Works, Does It Prove the Diagnosis?
I increasingly think we need to be careful about making that connection.
When a patient improves after treatment, it certainly tells us that something about the intervention had an effect. But it does not automatically prove that we completely understood the cause of the condition, or that the structure we treated was the main source of the symptoms.
The human body is not a machine.
It compensates, protects and repairs itself. Pain is also influenced by movement, emotion, fear, trust and expectation. One injured structure may be compensated for by others. A structural abnormality may exist without producing major symptoms. Conversely, severe pain does not necessarily mean that the most obvious abnormality on imaging is responsible.
More importantly, an effective treatment does not necessarily mean that the underlying problem has been fully resolved.
Some patients improve considerably, only to experience symptoms again months or a year later. If an intervention produces short-term relief without changing the major factors maintaining the condition, the improvement may be temporary.
Treatment success therefore tells us that an intervention had an effect. It does not automatically prove that our diagnosis or explanation of the underlying mechanism was completely correct.
Why Can Treatment Work Even When the Diagnosis Is Incomplete?
Sometimes the structure we treat may not be the primary problem, but the intervention can still influence other parts of the system.
If a clinician believes the quadratus lumborum is responsible for back pain and treats it with acupuncture, massage or soft-tissue techniques, the treatment may also affect surrounding tissues, muscle tone, pain perception and movement. The patient may improve even if the original explanation was incomplete.
The body is also recovering naturally. Many uncomplicated muscle strains and back injuries improve with time. During treatment, patients may also reduce heavy lifting, stop strenuous exercise and rest more. When they recover, it is easy to attribute the entire improvement to one treatment.
The experience of receiving care can matter as well. The patient is examined, given an explanation and receives treatment. This may influence how they understand their condition, how much attention they give to pain, and how confident they feel about moving again.
Trust and expectation can also contribute. Some patients have great confidence in a particular hospital, specialist or treatment. These factors become part of the overall treatment experience.
Improvement, therefore, may result from several influences acting together.
Surgery is not completely different in this respect. I have seen patients with shoulder pain whose imaging showed tears, spurs or degenerative changes. They underwent surgery and felt better for months or even a year. Both patient and clinician may understandably regard this as confirmation that the original diagnosis and treatment were correct.
But surgery is not an isolated event. There is anaesthesia, followed by rest, rehabilitation and changes in activity. The patient’s confidence in surgery may also influence the recovery process.
Improvement after surgery is real, but it does not necessarily prove that the structure treated during surgery was the only cause of all the patient’s symptoms.
Successful Treatment Can Reinforce a Clinician’s Own System
This is something I believe clinicians need to watch carefully.
We diagnose according to our own framework and treat according to our preferred methods. The patient improves and is satisfied. Naturally, we become more confident that our diagnosis, treatment and clinical system are correct.
When this happens repeatedly over ten, twenty or forty years, that belief can become very strong.
Clinical experience is extremely valuable. But successful experience can also trap us, because once a patient improves, it is easy to stop asking questions.
Why did this patient actually improve? Was the structure I treated really the main problem? Were other factors involved? How long will the improvement last?
If we stop asking these questions, we may remain increasingly comfortable inside our own system.
Acupuncturists become more convinced by acupuncture. Manual therapists by manual therapy. Injection specialists by injections. Surgeons by surgery.
Perhaps each of us is seeing only one part of a much more complex human problem.
How Do We Move Beyond Our Comfort Zone?
After decades of practice, a clinician’s system is built not only from knowledge but from experience, habits and confidence. Questioning something we have believed for many years is difficult.
But if we want to continue growing clinically, I think we still need to ask ourselves: Is this diagnosis really established? Is this positive finding actually the main problem? Have I missed something? Do I need to ask another question or examine something else? My treatment worked—but what exactly did it change? Will the result last?
We should keep asking why.
This is not about doubting our ability. It is about asking:
Is there still something I have not seen?
I am not writing this to dismiss any clinician or treatment, or to suggest that my own approach is better. It is mainly a reminder to myself not to stop questioning simply because a patient improved.
If another clinician reads this and decides to ask one more question, examine one more possibility or think one step further, then sharing these reflections has been worthwhile.
Effective treatment does not necessarily mean that we have fully understood the disease. A clinician’s greatest risk may not be a lack of experience, but becoming trapped by successful experience.
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When persistent pain does not respond as expected, reassessing the possible source of symptoms may be as important as choosing the next treatment.
Disclaimer
This article reflects Dr Win Huang’s clinical experience and is intended for general educational purposes. It does not criticise any individual clinician, profession or treatment method and does not constitute individual medical advice. Diagnosis and treatment should be based on each patient’s clinical circumstances.
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