It was a cliffhanger of an outcome – in a critical election between two candidates from opposite ends of the medical spectrum.

Dr. Alan Ruddiman garnered 945 votes, but Dr. Brian Day got one more, at 946.

And then, miraculously, in a recount, a single overlooked vote was found. And that single vote went to Dr. Ruddiman, which led to an exact numerical tie.

As a result, the organization that Drs. Ruddiman and Day aspire to lead — Doctors of BC — has decided to run the election again (a third candidate who attracted fewer than 300 votes has been eliminated).

Most doctors in British Columbia didn’t actually vote the first time around. Out of 10,000 eligible physicians, only about 2,100 actually cast their ballots. The initial winner thus received a mandate from fewer than 10 per cent of eligible voters.

That is indeed surprising, because this tight election outcome was between two candidates who are different in every fundamental way.

Who are these two doctors anyway?

Dr. Ruddiman is a family physician working in the town of Oliver, in the south Okanagan, a community of just under 5000. Like all primary care doctors, he is close to his community, and follows patients over many years. He’s a champion of rural medicine and of publicly funded health care.

Dr. Day, on the other hand, is an orthopedic surgeon specialist, living and working in BC’s largest urban area, owner of a private surgical clinic located a few hundred meters away from British Columbia's largest tertiary care hospital, the Vancouver General Hospital, where, by the way, patients from his clinic have to go if they develop post-op complications in his facility. Day has for two decades been an outspoken proponent of privately funded procedural care – so-called “two-tier medicine” – in which patients pay out of their pocket for the services they receive.

The general platforms of the two candidates diverge sharply. Ruddiman is engaged on a broad range of issues besides private versus public care, such as gender equity within the profession, the advancement of rural medicine, and the encouragement of young practitioners.

Day is focused on the singular cause of private, for-profit healthcare. He attributes the weaknesses and deficiencies of healthcare in Canada to a lack of access to pay-as-you-go medicine. He's even fighting with the BC government in court over this issue. (More on that later.)

Stylistically, the two candidates are also markedly different, although both are articulate and well spoken, and knowledgeable about medical politics and the structure of healthcare in this country.

Ruddiman is genial and upbeat – a glass-half-full person – who is comfortable addressing multiple issues, and doing so from a broad perspective, calmly laying out evidence for complexity.

Day clearly revels in the limelight and in banter with reporters. He uses simple analogies and folksy examples to make his points, driving home his message by repeating talking points rather than offering detailed evidence.

As a result Day, in his enthusiasm for his cause, has developed a reputation for playing fast and loose with the facts when he is in the public eye, in order to create colourful imagery. In this respect, he often comes across more as the classic politician.

The differences don’t end there

Ruddiman tends to be friendly and inclusive, a bit of a “nice guy” in a conversation, whereas Day is often intense, and not above aggressively dismissing – to their face – those who differ from his perspective.

During a recent debate on CBC Radio’s Almanac, going head-to-head with Dr. Vanessa Brcic, representing Canadian Doctors for Medicare (CDM), Day stated dramatically — several times – that 150 orthopedic surgeons in Canada were out of work because there are no jobs in the publicly funded system, conjuring up images in listeners’ minds of forlorn doctors being cold-shouldered by indifferent government officials.

But when a CDM analyst checked statistics for unemployed orthopedic surgeons, the numbers showed that only a handful or surgeons were unemployed on a year by year basis.

During the debate with Dr. Brcic, he called her well referenced position “faulty logic” – while offering little substantive evidence of his own.

And in an interview with CBC Radio Vancouver’s Early Edition, after calling the current president of Doctors of BC, Bill Cavers, “mistaken” on his key point, Day launched into a vituperative attack on Canadian Doctors for Medicare, accusing them of presenting “a slanted story from a fringe group of doctors that comprises a minute… percent of the doctors in Canada, that are out on a mission… and don’t check their facts before they spout them out” – without, once again, giving any clear basis for his attack.

Canadian Doctors for Medicare is actually a substantive national organization whose ranks are studded with academic and clinical physician leaders, and has had a major presence in the debate over for-profit vs publicly-funded care. Its critique of for-profit care has been detailed, cogent, and influential; it has been accepted as an intervenor in Brian Day's legal tussle with the BC government (more below).

CDM's past president, Dr. Danielle Martin, who holds a degree in public policy and is an assistant professor at the University of Toronto, famously testified before a US Senate committee in March of last year, rebutting hostile and ill-informed comments about Canada’s publicly-funded system from Senator Richard Burr so decisively that another Senator, Bernie Sanders, posted a video of the exchange. The video went viral, receiving 1.3 million hits.

At a structural level – the way they position themselves in the health care system – the two candidates could not be farther apart. Ruddiman positions himself as a strong supporter of the health care system, acknowledging its imperfections, but intent on working within the system to correct them. He sees himself as someone who wants to improve it, not tear it down and rebuild it.

Day, on the other hand portrays himself relentlessly as the permanent “outsider," a little bit of a stretch when he’s already served as president of the Canadian Medical Association. His latest handout for the re-election uses the word “outsider" twice in the first paragraph.

He offers himself up as the embattled little guy fighting for “patient choice,” facing off against the supposedly monolithic, indifferent and “monopolistic” public health care system, even though the Canadian system isn’t a monopoly – it’s well known that about 30 per cent of health care costs in Canada are already paid for privately. Because he’s constantly protesting against “the system,” he has become a magnet for protest of other kinds.

So is the Canadian health care system broken?

What is really going on in the health care system? And do British Columbians share Brian Day’s appetite for for-profit health care?

Apparently, to real outsiders, the Canadian system actually looks pretty good – and not because of Brian Day’s favoured user-pay component.

American family physician Dr. Emily Queenan described in the Toronto Star why she recently left the US and moved her practice to Canada. It was because “I’ve… witnessed the painful and continual shifting of medical costs onto my patients’ shoulders,” mostly through private insurance plans. Incidentally, more physicians are moving from the US to Canada than the other way around.

And there are specific made-in-BC issues affecting health care delivery. In an article in the Canadian Family Physician journal last month, entitled Ecology of Health Care in Canada, Dr. Moira Stewart pointed out that BC physicians are sometimes reluctant to innovate, being the least likely to use nurses and other assistants in their practices, despite their proven value in increasing services and lowering costs. So there are multiple other ways the system could be improved besides adding more private competition.

Brian Day, in his position of “outsider” critic of Canada’s system, has often gleefully cited a report by the US Commonwealth Fund which compares the American healthcare system to the systems in 10 other wealthy nations. Entitled Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally, this “snapshot” report is drawn from a much larger and more detailed document. Both focus on the gross failings of the notoriously expensive and inequitable US health care system – a system which is, of course, heavily privatized.

Day never tires of pointing out that this snapshot places Canada as 10th out of 11, compared to European countries and the US. But he gives few details.

Maybe that’s because this snapshot and the larger report on which it is based actually show that the “best” country (the UK, the home of the first comprehensive publicly funded health care scheme) and the “worst” the US, the home of corporatized health care, are indeed exceptional. But all the other countries, including Canada, are generally within a few percentage points of each other.

Furthermore, neither report supports the principle of privatized, for-profit healthcare.

In fact, here’s what the snapshot report has to say about what the authors call “equity” in the US :

“Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.“

Whether it’s one clinic, or a hundred clinics, for-profit health care generates these kinds of outcomes.

A recent article in the medical literature showed that of the 50 U.S. hospitals that charge patients the highest margin over their costs, 49 were private for-profit institutions.

In Canada, B.C. has now taken over from Alberta as the go-to province for privatized health care. And it’s not always a pretty sight.

I know first-hand how this can work, because I’m a practicing family physician in B.C.

One of my patients came to my office in distress. He needed a shoulder surgery. He had called the surgeon’s office who I had referred him to, a highly skilled practitioner, after a couple of months. The surgeon’s staff had said it would take 14 months to see him, but suggested my patient try his “private” office. There my patient found out that if he paid $500 out of pocket, he could see the same surgeon in two weeks.

He was torn, because he could ill afford the money. Eventually, he paid it, because his small seasonal business depended on the surgery. It was performed a few weeks later – at a publicly-funded facility.

And then there’s the legal complication…

There is one more difference, and a very important one, between Brian Day and Alan Ruddiman.

Brian Day, at his pugilistic best, is enmeshed in a legal battle, initiated by his corporation, against the Medical Services Commission and the BC government, arguing that the ban on physician extra billing and hospital user charges violates the Canadian Charter of Rights and Freedoms.

Ruddiman is engaged in no legal actions, and by all accounts doesn’t appear to be inclined that way.

In May, 2007, after receiving multiple complaints from patients of Day’s Cambie Surgical Center that they had been billed extra for the services they had received, billed privately and through the publicly funded system, which is forbidden under the current system, the authorities stated that they were going to audit his books. (Day’s Wikipedia page says that he “invited” the government to look at his books, but the record shows the opposite to be true.)

After delaying his response, and producing, for some time, only bits and pieces of the requested information, Day decided to go on the offensive. In conjunction with other private clinic proponents, he inspired four of his clinic patients to launch a lawsuit against the government, alleging that his billing practices, although currently illegal, were his right and privilege.

At meetings and in public statements, he has made no mention of his conflict of interest in this matter, instead repeating the talking point that he is just enabling “patient choice," the choice for wealthy people to jump the queue. He has presented this action, as have many other proponents of privatized care, as a solution to extended wait times for treatment, even though detailed research by independent scientists has suggested that it has no effect or even makes them longer.

The case is slowly dragging through the courts, the longest delay having occurred because Day’s lawyers have asked to seek an out-of-court settlement with the BC government. The matter will come before a judge sometime towards the end of 2015 or early 2016, and will take many months to work through – possibly extending into the term of the next president-elect of the Doctors of BC in June, 2016.

So how will this turn out?

Will the next president be Alan Ruddiman or Brian Day? The team player or the “outsider”? Is the appetite for privatized healthcare in Canada strong enough to bring victory for its most visible enthusiast?

Eastward cross the Rockies, far away from BC’s medical brouhaha, another election has just taken place. Rachel Notley is now installed as Alberta’s new premier, replacing a 44-year Conservative dynasty with new a new bloodline from, of all sources, the New Democratic Party.

On April 29, Ms. Notley stood in front of a private healthcare clinic in Calgary, and the Calgary Sun reported as follows: “Private clinic health care is about building a two-tier system where the wealthy, the people who Jim Prentice and his friends represent, can pay to jump to the head of the line instead of treating people on the basis of need.”

Notley said private clinics draw resources away from the public health care system, ultimately undermining it.

"Instead of more of these clinics, I’m proposing we reverse the billion-dollar cutback to health care Mr. Prentice is asking you to vote for in this election and I’m also proposing that we get rid of the regressive health levy,” she said.

“And I’m proposing that we improve our public system with better diagnostics, better long-term care, better mental health care and just plain better health care overall, including better cancer care here in Calgary.

“On this issue, there’s a stark contrast between the vision I’m putting forward and what Mr. Prentice has to offer.”

Despite this direct frontal challenge to privatized medicine, we all know how that election turned out.

We’ll soon find out how the Doctors of BC election turns out.

Voting for the new president-elect the Doctors of BC began on June 5, and ends on June 18.