Dr Huang’s Clinical Reflections (12)
When One Treatment Works Immediately: Clinical Skill or Showmanship?
By Dr Win Huang, PhD (Chinese Medicine & Acupuncture)
A few days ago, I saw a patient who had been experiencing shoulder pain for one or two months.
Several months earlier, she had experienced almost exactly the same problem and had seen another acupuncturist. According to her, there was not much questioning or examination. She simply lay down, received acupuncture for about an hour, and afterwards her shoulder pain disappeared.
The next day, she was still pain-free, and the improvement lasted for quite some time.
When similar pain returned, she wanted to see the same practitioner again, but he was no longer working there. Eventually, a friend referred her to my clinic.
I Saw More Than Just Shoulder Pain
When I took a more detailed history, I found that she had not only shoulder pain, but also upper back pain and numbness in her hand.
When these symptoms occur together, I cannot simply treat the problem as local shoulder pain.
I examined her neck, the scalene region and several clinical findings related to possible nerve irritation. Based on the history, symptom distribution and examination, I considered irritation around the scalene region to be clinically relevant.
I explained why I was examining her neck when her main complaint was shoulder pain, why the hand numbness mattered, and why the shoulder, upper back and hand symptoms might need to be understood together.
But gradually I realised that she was not particularly interested in my explanation.
What she remembered was very simple:
“The last doctor treated me once, and the pain was gone.”
That made me wonder: if my examination is more detailed and my clinical reasoning is sound, but my treatment does not work as quickly as the previous treatment, how will she judge me?
Perhaps the answer is equally simple:
The previous doctor was better. One treatment and the pain disappeared.
That question stayed with me.
Patients and Clinicians Live in Different Medical Worlds
Patients build their understanding of illness from many sources. They may receive a diagnosis from a specialist, see “disc protrusion” on an MRI report, hear about sciatica from a friend, and then search Google, YouTube or AI for more information.
Eventually, these pieces form a story:
“My disc is pressing on a nerve, so my leg hurts.”
“My neck is compressing a nerve, so my hand is numb.”
The story may be medically complete or incomplete, but it is how the patient understands what is happening to their body. A patient does not need to become a doctor.
The same applies to treatment outcomes.
If pain was 8/10 yesterday and 2/10 today, that improvement is real. If the arm could not be raised before treatment but can be raised afterwards, that change is real. If pain no longer wakes the patient at night, that experience is real.
When a patient says, “I feel much better,” that is their experience.
But a clinician has a different responsibility.
A patient may tell me, “My MRI shows a disc protrusion pressing on the nerve, and that is why I have sciatica.”
I cannot simply accept that explanation and treat accordingly. I still need to take the history, examine the patient and determine whether the imaging findings actually explain the current symptoms.
Sometimes they do. Sometimes they do not.
If I treat another clinically relevant problem and the pain improves significantly, that response matters. But it does not automatically prove:
“I treated the disc protrusion.”
A patient may understand the improvement that way.
A clinician should be more careful.
Immediate Results Are Not the Same as Showmanship
When people talk about clinical “showmanship”, they often think of dramatic results: one needle and the pain disappears, one technique and movement immediately returns, or an unusual point that appears to produce an instant change.
I no longer think those things are necessarily showmanship.
If a practitioner genuinely reduces a patient’s pain with one needle, that is clinical skill. If a technique immediately improves movement, that is a genuine treatment response.
The patient I described really did improve after her previous acupuncture treatment, and the benefit lasted. I have no reason to dismiss that result simply because I later performed a more detailed assessment.
Perhaps the previous practitioner identified the important problem very quickly through experience.
So:
Immediate improvement is not showmanship. Good clinical skill is not showmanship.
The important question is:
What does that improvement actually prove?
If the pain disappears, does that prove the original diagnosis was correct? Not necessarily.
Does it prove the proposed treatment mechanism was correct? Not necessarily.
Does it prove that a particular anatomical structure has been “fixed”? We should be even more cautious.
This is where I think clinical showmanship can begin.
The problem is often not a false treatment result. It is giving a real treatment result an explanation that goes beyond the available evidence.
If that explanation is then combined with claims such as “other practitioners cannot find this” or “only my technique can treat this”, a genuine clinical result can quickly become a story about a “miracle doctor”.
But Clinical Modesty Can Go Too Far
I have sometimes gone too far in the opposite direction.
Because I place great importance on diagnosis, I often reassure patients by saying things such as: “Your MRI does show a disc protrusion, but it may not be the main reason for today’s pain,” or, “This may be more related to a muscle or peripheral nerve.”
My intention is to reduce unnecessary fear.
But sometimes I have made the problem sound too simple.
The patient may hear, “It is only a tight muscle,” and conclude that the clinical assessment was nothing particularly important.
Yet the real clinical value is not simply that I “released a muscle”.
It is recognising that the previous diagnosis does not fully explain the symptoms, identifying a more plausible source through examination, treating it selectively, and then reassessing the original symptoms and clinical signs to see whether the reasoning holds.
That is a clinical chain of evidence.
Avoiding showmanship does not mean undervaluing clinical judgement.
What Is Real Clinical Skill?
After many years in practice, I increasingly think clinical skill has at least three levels.
First, see the problem clearly. Do not allow an existing diagnosis, imaging report or disease label to replace your own history taking, examination and clinical reasoning.
Second, treat effectively. Diagnosis ultimately has to serve treatment. Has the pain decreased? Has function improved? Is the patient sleeping better? Have the original clinical signs changed?
Third, understand what the treatment response actually means.
This may be the most easily overlooked level.
A patient may experience dramatic improvement and think the doctor is remarkable. But the doctor should not start believing that every explanation must therefore be correct.
A clinician needs to know where the evidence ends.
Patients naturally focus on results.
Doctors must look at the result, but also at the process and the evidence behind it.
So when I now think about “one treatment and the pain is gone”, the most important question is no longer how impressive the treatment looks.
The more important question is how the clinician interprets what happened afterwards.
Clinical skill is not only seeing clearly and treating effectively. It is also knowing exactly how far the evidence allows us to explain the result.
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