Her question left me momentarily perplexed: “Can you draw the U.S. healthcare system for me? I do not know anything about it. How does it work?” Without hesitation, but with a quizzical look remaining on my face, I took hold of the marker and approached the white board. Above all else I knew many Germans enjoyed details—they could appreciate and see the connections (or lack thereof) of a system and its disparate parts, but where to start?

I decided to stop thinking and just let instinct take over. I started by drawing a hospital, a bit off center to the right, then I drew doctors near the hospital, these represented specialists. Next, I drew an ambulance to represent emergency medicine. Beneath the doctors I drew a primary care clinic. then I drew a patient standing outside the primary care clinic. I drew arrows from the patient and soon had a nice sketch of the patient accessing primary care, from there the patient was referred to a specialist.

Then, the questions: “Does the patient have to pay anything? How much does it cost?” This is where things got interesting. In the upper left corner of the board I drew the White House, Congress, then a large box underneath to represent the Department of Health and Human Services. I quickly scrawled Medicare, Medicaid, and S-CHIP with some basic information about the populations they served and dollar signs next to each. On the other side of the board I drew a large box with several dollar signs to represent the U.S. private insurance industry. I drew a circle in this box to represent “employers.”

Still the questions remained: “How much do they pay? When do they pay?” I suddenly realized the complexity of the conversation was immense—there is no good translation for “it depends” in the German language. In German language and culture—most situations things either “are” or they “are not.” I explained that if the patient has private insurance they pay a co-pay, receive a bill for hospital-based services, and the private insurer may or may not cover the services provided. She looked at the board and said “Das ist zu komplizert,” translation: “That’s too complicated.”

We started talking about the “missed connections.” For example, if a patient goes to a different hospital or visits a different provider a patient would have a complete history completed. The physician would have little knowledge or background of pre-existing conditions, allergies, etc. In America we “expect” this. Her immediate analysis: “Das ist zu teuer,” translation: “That’s too expensive.”

Our dialogue lasted over 30 minutes. Leaving the conversation, I wasn’t sure if I should have feel “accomplished,” for having the dialogue, or “defeated” for describing a something that made no sense to my audience.

On the way home, I replayed the conversation in my mind and immediately recognized the hubris of my comments and perspective. I started to view the U.S. healthcare system through foreign eyes and more importantly through the eyes of a patient. I realized my immediate conflict stemmed from where to start and just branched off from there; what would be the nucleus of the conversation (and diagram) from which I could create a simple, interconnected web of healthcare harmony. In hindsight, I did not place anything in the center of the board, but I started with the hospital (35% of U.S. healthcare expenditures). Whether or not this was based upon my background as a hospital administrator or in reality, I know not.

As a believer in patient-centric healthcare, I started thinking of ways to put the patient in the center, and could think of very few models in current use. For example, just this week Reuters released a story with the headline: Family-centered Rounds More Common, Obstacles Remain. This article discusses the American Academy of Pediatrics’ recommendation that teams in pediatric wards conduct rounds in patients’ rooms, with parents present and involved in the discussion. This guideline from AAP recommends that hospitals move toward “family-centered care,” designed to get parents more involved in decisions about their children’s care. Sounds patient-centric to be, as such it is difficult to comprehend why this is not a commonly embraced medical practice.

Overall, I realized how foolish I appeared when it dawned on me that this woman could go to any “state” in her country, could visit almost any physician, and she had an understanding of how much she would pay and when she would pay. For the German people, there is some degree of comfort found in order, being able to predict the outcome of a system or process.

But I still can not help but wonder, “Why is patient centered healthcare not more readily practiced?”