The low hum of soft rock drifts through the operating room. A shortish, 63-year-old surgeon in white rubber boots stares at the video screen, his left and right hands deftly manipulating a series of instruments through two tiny incisions in Dennis Geidt's left shoulder.
After much meticulous work inserting screws and tying knots, the surgeon informs the anesthesiologist: "This is it, Bill." A brief flurry of activity, then: "There's the tendon, reattached."
Moments later, an hour after he began, Brian Day is rolling up his light-blue gown, stripping off gloves, mask and skull cap and heading out the door.
Other than the enduring magic of arthroscopic surgery, there is little that is remarkable about this tableau, except for one thing. Some would call it a crime scene.
Dr. Day and his 76-year-old patient have willfully contravened a sacred tenet of the Canada Health Act and British Columbia's own medicare legislation. Namely, that Canadians may not buy their way to the head of the queue for medically necessary treatment.
Mr. Geidt, the man on the operating table, has done exactly that. Rather than wait the year or longer he was told it would take to be treated under medicare, Mr. Geidt, racked by pain, opted to fork out $7,010 from his own pocket to have his left shoulder repaired - within weeks - by Dr. Day.
Neither Mr. Geidt nor Dr. Day is in any danger of being cuffed and carted away. The privately owned Cambie Surgery Centre, where Dr. Day plies his skillful trade, has been allowing patients to pay for such procedures for years. So far, authorities have done little more than wave an admonishing finger.
"It's the Neville Chamberlain approach," said health-policy consultant Steven Lewis, a strong critic of for-profit medicine. "Peace at any cost. Don't ask. Don't tell."
No one could accuse Dr. Day of not telling. As he said matter-of-factly of Mr. Geidt and countless previous patients who have sought costly but speedy relief at the Cambie clinic: "It is a violation of the B.C. Medicare Protection Act, and I make no apologies for that that."
Is it sustainable?
The clash between Dr. Day and the Canada Health Act is a compelling example of the need for a vigorous, new, public examination of our creaking medicare system. Is it sustainable? As the price of providing universal health care continues its relentless drive upward, where will the money come from?
With federal transfer payments to the provinces and territories set to expire in just three years, critics of the status quo say we should consider a bigger role for private care in a system that is largely publicly funded.
What began as a government-paid insurance program to ensure physician and hospital care for all has expanded over time into an awkward amalgam of public and private funding. Distinctions between the two are often blurred.
Today, The Globe and Mail begins a weeklong series on health care, designed to clear up some of this confusion between private and public, and set the tone for an informed discussion on where to go from here.
While never more urgent, a debate on the sins and virtues of private, profit-oriented health care is hardly new, and Dr. Day's state-of-the-art facility on a lovely, tree-lined Vancouver street remains ground zero.
No one has been more prominent than Dr. Day in espousing the controversial right of patients to pay for their own health care at for-profit clinics. His clear, outspoken views propelled him to the presidency of the Canadian Medical Association in 2007-2008.
While critics disparage the concept as two-tier medicine, the veteran orthopedic surgeon says it's the future.
"It is inevitable," he said. "As baby boomers start to retire, the system is going to be hit with a tsunami of illness."
With the use of new, expensive technology expanding at the same time, costs will continue to rise dramatically, Dr. Day contends, and pouring more and more public dollars into medicare is simply not sustainable. "There's only one other type of money out there, and that's private money."
Some provinces are already confronting the challenge, centralizing heavily sought procedures at designated hospitals, and increasing funding. They report success in reducing waiting times and increasing patient volume for many operations in demand.
B.C, in fact, is pioneering a concept known as patient-focused funding, a system that pays institutions for each procedure instead of providing them with huge sums, regardless of what they do.
Dr. Day, a long-time advocate of the idea, says the private sector should be allowed to compete for those patients. "There would then be no queue jumping, because there would be no wait lists."
He believes the decades-long debate about the role of private clinics in Canada's public health-care system has finally reached a tipping point. There will simply not be enough tax revenue for medicare to manage the pending influx of aging baby boomers, Dr. Day argues, without opening the door to the private sector.
Full day of surgery
If he is correct, this is what the future looked like on an unseasonably warm fall morning at the Cambie Surgery Centre.
His full day of surgery was replete with patients thumbing their noses at the principle that no one should be able to buy their way to the operating table. Four had travelled here from Alberta, rather than wait for publicly funded treatment in their home province.
One was Daniela Acimov, a dental assistant. Dr. Day's initials were printed on her right knee in big black letters, marking the spot where he would reconstruct her torn anterior cruciate ligament.
After being told she faced lengthy waits for both consultation and surgery, Ms. Acimov opted to have her operation at the Cambie clinic for a hefty price tag of $10,250, some of which she may be able to reclaim from Alberta's health-care plan.
"I couldn't believe how hard it would have been to get this done in Alberta," Ms. Acimov said, before being wheeled into the operating room. "I was in a lot of pain. I couldn't go to work. It was just ridiculous."
Dr. Day pioneered arthroscopic ACL reconstruction. He's done thousands over the years, and he has no problem combining a steady stream of chatter ("It's supposed to be 23 degrees today…") with the work at hand.
But near the end, it was all business. "The drill next," said Dr. Day, as the complex, interior network of bones, sockets, tendons and ligaments played dramatically across the video screen. A short while later, there was an audible tap, tap with a small hammer on an awl-like instrument, then bang, bang, bang.
"I'll have a 9x30 tibia screw, please," he told the nurse. Soon, the operation was over.
At noon, there was time for a brief checkup on patient Mike Klein, a stocky equipment operator wearing a T-shirt extolling jailed pot crusader Marc Emery. Mr. Klein's knee operation was paid for by WorkSafeBC, formerly the Workers' Compensation Board, which has been using Dr. Day's clinic to obtain early treatment for injured workers since the mid-1990s. Their clients still comprise nearly 40 per cent of the facility's patients.
"It's worth it," Mr. Klein said. "If I had to wait two years, that sucks."
Dr. Day never tires of pointing out the ethical conundrum of having patients injured on the job green-lighted for treatment at his clinic, while individuals who suffer identical injuries at home have to wait months for their procedures at public hospitals.
WCB patients, plus members of the RCMP, the military and inmates of federal prisons, are excluded from the Canada Health Act.
There are halting moves to rein in the Cambie clinic's skirting of medicare rules, which Dr. Day says provides about 10 per cent of its business. B.C. health officials are seeking an audit of the facility, and the B.C. Nurses' Union has a longstanding lawsuit to force a government crackdown on Dr. Day. Both cases have bogged down in court.
"The Canada Health Act is more of a bikini than full Islamic regalia," said Mr. Lewis, the health policy consultant. "It doesn't cover every conceivable circumstance. There is deliberate, unenforceable vagueness on what must be carried out in the public sector."
For his part, Dr. Day has filed a B.C. version of the landmark Chaoulli case that opened the way for residents of Quebec to buy health insurance for private delivery of medically necessary procedures. "If we win, it will be the best thing that ever happened to medicare, because medicare is going bankrupt," Dr. Day said.
Critics despair at his prescription for the future, however, arguing that he plays fast and loose with facts and medicare is not doing nearly as poorly as he suggests.
Mr. Lewis agrees that medicare needs to improve its delivery of services, but the answer is not to allow someone to pay for something others can't afford. "That's not fair," he said. "The solution is to make the public system good enough, so we don't have facilities like Dr. Day's clinic cherry-picking low-risk, high-volume, lucrative services."
No one should be too surprised by Dr. Day's incessant punching away at Canada's health-care system. He comes by it honestly. A schoolmate of Paul and George of the Beatles, Dr. Day was raised in the rough, impoverished Liverpool district of Toxteth, He was a promising young boxer, until he stopped growing at 5 foot 4. He retains a scar from a one-sided knife fight when he was 10.
His pharmacist father was gunned down by a couple of thugs looking for drugs during the Toxteth riots in 1981. Several years later, his mother died at 61, a victim of misdiagnosis.
It's a background that has doubtlessly helped forge Dr. Day's combativeness and determination to stay the course. "There is nothing unethical about spending your own money on your own health care, and no one will ever convince me that it is," he declared.
The pros and cons of private-versus-public meant little, however, to Dennis Geidt, willing to pay to stop pain so severe he couldn't pick up a jug of milk or sleep at night. He just wanted the hurting to stop.
That night, in a downtown Vancouver hotel, Mr. Geidt, who travelled from his Rocky Mountain home in Revelstoke, B.C., for the operation, had his first pain-free, restful sleep in months.
"It was damned expensive," he said. "But when you're my age, who cares?"