TORONTO -- "Dr. Hudson doesn't follow the rules," says the nurse with a certain bemused exasperation as she monitors the station outside the operating room at St. Michael's Hospital in downtown Toronto.

There are many rules, committees, boards and bureaucrats governing the life of the doctors in Canada's unique socialized medical system. But they hardly seem capable of erecting big enough obstacles to thwart Dr. Alan R. Hudson, the 49-year-old chairman of the University of Toronto's division of neurosurgery and a man with enormous physical and intellectual energy. He seems to delight in devising schemes to make an end-run around the hall monitors and bean counters who oversee the system of health care in Canada.

There is, to take one example, the way Hudson arranges his surgery schedules, putting easy cases first, hard ones last.

"Time is golden for me," he says. "You watch, they'll be hounding me all through the day, asking when am I going to get finished because they don't have enough nurses to cover me through the afternoon."

That's why he has taken to putting off his most serious cases until the end of the day, confident the hospital will not send the operating room nurses home in the middle of a brain operation just to hold down the overtime budget.

"It means I'm doing the big difficult case in the afternoon when I'm more tired, and that does not make sense to me. If I start on the big case, they'd cancel short cases since they have no nurses," he says. "That's a consequence of the system. In the Mayo Clinic that would never happen. You'd book patients in a rational order."

Despite the problems, Canada has developed one of the world's most complete publicly supported health systems. The government's role is essentially that of running a health insurance system. Whether they are millionaires or paupers, patients have the same access to good quality health care. They are free to go to any doctor and hospital of their choice.

Dr. Hudson's first case on this day involves his internationally recognized specialty, the correction of peripheral nerve damage. In addition to performing scores of such operations on patients, in his laboratory downstairs in the hospital, he supervises experiments on nerve transfers from one monkey to another.

In the operating room, only an arm and a leg of an elderly woman peek out from covers. Her right arm has become useless because of her injury. Dr. Hudson and his staff are briskly professional while performing the delicate surgery, but the atmosphere is unexpectedly relaxed. Among the myriad tasks of the head nurse is responsibility for changing the popular music tapes on the portable stereo perched on a ledge. Hudson tells her he does not think the Pointer Sisters would be appropriate as he skillfully manipulates a tiny needle and nylon sutures under an operating room microscope to sew nerve ends together. Using nerve material from the patient's leg, he cuts and reroutes nerves in her arm, hoping that the nerves there will grow back. It is the first of four operations for the day. He has scheduled a difficult brain tumor surgery as the last case of the day.

The operating room appears outdated. A plaster tile has fallen from one wall, and the equipment has not been state-of-the-art for years. Later, he describes the facilities as "good but not excellent."

There is ongoing conflict between Ontario doctors and their government overseers about equipment, fees and working conditions. Having just completed negotiations over rates of payment for medical services, they are now battling over government plans to cut 300 residency positions for medical studies over the next five years, which would limit the pool of future physicians.

For 26 days last summer, doctors restricted emergency room services at more than two dozen hospitals in the province to protest a law -- carrying fines ranging up to $1,000 -- that prohibits them from levying extra charges on patients in addition to fees reimbursed by the government. While Dr. Hudson objected to that protest and did not participate, he has his complaints.

"The whole system here is one of flattening toward the middle," Dr. Hudson says. "We can't get onto new technology quickly. It has to go through endless committees and more committees and reviews and so on. In terms of our world posture, all the good research on {new equipment} has been done before we get our first one. It's hard for us to keep up in what is a fast-moving technological world because our system just won't allow it. Our system won't allow the risk of a big capital investment for something that may turn out to be a bust.

"It's a reflection of the different way of life. The entreprenurial spirit of the U.S. encourages putting a man on the moon. Canada would never put a man on the moon. They'd still be discussing that in a committee.

"Canada doesn't have slums. The United States does."

On balance, however, Dr. Hudson comes out in favor of Canada's system of government-financed universal health insurance. It is a desirable medium, he says, between the rigidities of Britain's system, where he worked for three years as a resident, where doctors get a flat salary regardless of the amount of work they do, on the one hand, and the gross inequities of the American way of medicine, on the other.

"In Canada, health is a right," he says. "In other words, I can't pay more money and get more water out of my tap. I can't pay more money and get a fire engine to come in and put out a fire out because the poorest guy and the richest guy are getting the same thing. Nor can you pay more money and get better health care.

"When I go to the States, I see some desperately ill patients being looked after by very junior resident staff with very little supervision. That would just never happen here. Those are indigents, those are blacks, those are people in county hospitals."

As a standard practice, Dr. Hudson is present for every operation of his patients, and he sees every one coming into his clinic. An associate and nurses do the work-up but he examines each one, racing through a caseload of 21 patients in three hours one afternoon last week, a moderate day, he said. They range in age from a bouncy 7-month-old girl who had suffered serious nerve injury during a difficult delivery to an 82-year-old man with back pains and leg pains, among other problems. Nearly three of four who come to the clinic are men under 40 who were injured in motorcycle accidents, skiing mishaps or sports contests.

The way the system works, patients present their plastic government insurance card, which is impressed on a slip about the size of a credit card charge. A code is entered, the bill is sent off to the government paymaster and, at the end of the month, Hudson is reimbursed.

Occasionally, he gets patients from the United States, and his secretary "goes into orbit" when confronted with the detailed and complicated U.S. insurance forms. For Canadian patients, there is a simple four-digit code for surgery to remove a brain tumor, for example, and the charge is $663. A physical examination costs about $30; child delivery runs about $300. The patients do not see the bill, and Canadian doctors do not have the problem of their American counterparts, who often must spend hours explaining procedures to insurance companies and or chasing deadbeats to get paid.

Dr. Hudson finds his Canadian patients generally more trusting and less questioning than the Americans who come up. But, he says, "one of the downsides of our system is overutilization by the patient. Say, a patient comes to me with back pain and I say, 'You don't need surgery.' The next week, he goes and sees someone else. Of course, each time he does that he's generating another bill and hence costing health care dollars."

There have been proposals for levying a user fee to discourage overutilization, but like the extra billing controversy that led to a job action last year by doctors, the idea has been rejected because of concern about the burden it might put on the poor.

On the positive side, fear of malpractice suits is minimal compared to his American counterparts, he says. In 17 years in practice, only three suits have been brought against him. Two were withdrawn by the plaintiffs before trial; the other he won. His malpractice insurance premiums are about $8,000 a year, he says, or about one tenth the amount neurosurgeons in the U.S. pay.

"When I go to the United States and talk to my friends, within two minutes, they're talking about their suits," he says. "That's all they talk about."

The big difference between the two countries is that in Canada malpractice cases are tried before judges, not juries, settlements are much smaller and courts do not permit lawyers to take a case on a contingency basis. Attorneys' fees are a flat rate and not based on whether the plaintiff wins or loses or on the size of any settlement.

Although the medical systems are very different, there is close cooperation between Canadian and American researchers, he says. His closest collaborator on nerve research is at the Louisiana State University medical school in New Orleans. He says he is currently involved in another $20 million project on stroke prevention that is funded by the U.S. National Institutes of Health.

"In terms of the U.S.-Canadian aspect of all this, there is no border, medically," he says. "American surgeons have been very friendly and cooperative with Canadian surgeons."

Hudson says his annual six-figure income is on a par with U.S. neurosurgeons at teaching hospitals. But, he says, "the income of the private practioner in the U.S. is so far ahead of me that it's out of sight."

Although he says he will never be wealthy from his earnings, Hudson, who was born in South Africa but has become a Canadian citizen, does live comfortably and is able to put four children through college. "I have a country place. I have a comfortable car. Okay, so I don't drive the world's most expensive car. Who cares? What do I drive? I drive a Pontiac. In the States, I'd be driving a Cadillac or a Mercedes but who cares, it's four wheels." Abruptly, he reconsiders. "I like driving a Mercedes. The question is how important is it to you."

"I get paid about what I deserve to be. You see, it's very hard to answer this question: If I take a brain tumor out of you or your family member and save your life, is that worth a television set, is that worth a car, is that worth a house? I mean how do you possibly value something like this? I do know that in American private medicine, surgery, some things are obscenely overpriced."

And, despite his complaints about equipment and shortage of nurses, he says he firmly believes that there must in Canada be cost-conscious overseers of doctors. "There's no question that health care bucks have to be run by bureaucrats," he says. "If you leave it to the doctors, there will be no roads, no education, no fire stations. Nothing."

"Each country has to decide what percent of the gross national product it is going to spend on health," he says. "Then you decide how to get the best bang for the buck."

Washington Post researcher Nancy Kroeker contributed to this article.