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In Reply to Starr et al

Montori, Victor M., MD

doi: 10.1097/ACM.0000000000002706
Letters to the Editor

Chair of the board, The Patient Revolution, and professor of medicine, Mayo Clinic, Rochester, Minnesota;; ORCID:

Disclosures: The ideas discussed in the essay that prompted this exchange and in this letter per se are drawn from Montori VM. Why We Revolt—A Patient Revolution for Careful and Kind Care. Rochester, MN: The Patient Revolution; 2017. All proceeds from the sales of that book support the mission of The Patient Revolution (, a nonprofit organization dedicated to promoting careful and kind care for all.

I appreciate Starr and colleagues’ comments, which share my concern for industrial health care and my hope for careful and kind care for all. Words matter, and as their letter suggests, the pursuit of value could be driven by a commitment to patient-centered care. In that way, care can produce more value when it leads to greater benefits to patients (e.g., improvements in outcomes) at lower costs (i.e., burden of treatment). However, as physicians we rarely know what care approach best reflects what matters to each patient, as noted by the low prevalence of shared decision making.1 We also seldom measure how disruptive our care is to our patients’ lives.2 Both issues indicate that we rarely mean patient-centered care when we refer to high-value health care.

I agree with my colleagues that the concept of care could be made evident to medical students through thoughtful and nuanced teaching of value. Yet, I would put forward that relating value to care keeps business ways of thinking and industrial ways of acting at the forefront, where patient-centered care should be instead. Medicine and nursing have a strong tradition of care from which students can appreciate the shortcomings of industrial health care unambiguously and place care for and about patients above all else. Disciplined business processes should support and enable their commitment to care that is safe and elegant—care without waste or haste—and that is careful and kind. For this, I believe we must turn away from industrial health care in practice and language.

Victor M. Montori, MD

Chair of the board, The Patient Revolution, and professor of medicine, Mayo Clinic, Rochester, Minnesota;; ORCID:

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1. Institute of Medicine. Shared Decision-Making Strategies for Best Care: Patient Decision Aids. 2014.Washington, DC: National Academy Press.
2. Spencer-Bonilla G, Quiñones AR, Montori VM; International Minimally Disruptive Medicine Workgroup. Assessing the burden of treatment. J Gen Intern Med. 2017;32:1141–1145.
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