Lying in a cold operating room surrounded by the health-care team, I watched trainees gather around to observe my surgery. Their presence was anticipated, given the central role hospitals play in health‑professions education. Yet as I lay there, vulnerable and exposed, I felt less like a person and more like a teaching case.
That experience revealed something larger: an educational system that continues to centre around hospital‑based observation even as many patient needs are shaped well beyond hospital walls. What unfolded in that OR was not an isolated moment, but a reflection of a broader structural misalignment in how health professionals are trained.
Canada’s main response to its health‑workforce shortage has been to train more health professionals. But more trainees do not automatically mean a better‑prepared workforce, nor do they guarantee better care if education remains disconnected from the needs of patients and communities.
Building healthier communities requires focusing not only on treating illness but on understanding the whole person in the environments where health is shaped. Hospitals treat the most acute, high‑stakes moments of illness and are essential training grounds for complex care, but they show far less about the everyday challenges, relationships and social conditions that shape health in the community. They also reflect the experiences of those who can access the system while overlooking the needs of those who struggle to receive care at all. As a result, learners are being trained in environments that no longer reflect the places and conditions where the greatest barriers to access exist.
Historically, training learners in hospital environments made sense. Operating rooms were once called operating theatres, drawing on 19th‑century amphitheatre‑style teaching where procedures were performed before observers. At a time when hospitals dominated both care and education, learning through observation in centralized institutions was logical. Today, amid rising chronic disease, an aging population and persistent inequities in access to care, this model feels increasingly disconnected from contemporary practice and from the contexts in which learners will work.
As the Lancet Commission on Education of Health Professionals for the 21st Century has noted, training remains grounded in static, hospital‑oriented curricula misaligned with improving population health or equity. Canada recognized this more than a decade ago. The Association of Faculties of Medicine of Canada’s 2010 report, The Future of Medical Education in Canada: A Collective Vision for MD Education, called on all faculties of medicine to embrace social accountability and diversify where students learn. That call was answered only in part. Rural and distributed training has expanded considerably, yet learning in the community settings where care could have the greatest impact for historically marginalized populations remains largely absent from core curricula. The result is a workforce trained at a distance from the communities it is meant to serve, and patients who go without care in the environments where it would matter most.
For learners, hospital environments show only one part of people’s health journeys and offer a limited view of the contexts that shape health in everyday life. As training programs expand to meet workforce demands, students remain clustered in the same clinical environments, limiting their exposure to the broader realities of health beyond hospital settings. At the same time, hospital‑based training sites are increasingly strained by staffing shortages, clinical demands and limited supervisory capacity. Modern units, redesigned for efficiency and privacy, offer little physical space for teaching growing cohorts of students, and a shrinking pool of clinical staff is expected to supervise more learners in less time. As learner numbers grow, it is reasonable to question whether hospitals should continue to host most clinical education, rather than expanding training into community‑based settings.
For patients, hospitals can be difficult to access, especially for those facing social, geographic or economic barriers. Many delay seeking care until their conditions become urgent, which leads to costly, late‑stage interventions that could have been avoided with earlier, community‑based care. Others avoid seeking care altogether because of overcrowding, long waits and environments that can feel intimidating or unwelcoming. Expanding high‑quality training into community clinics, long‑term care facilities, homeless shelters and mobile care settings could improve access, reduce pressure on strained hospital systems and better prepare learners for the realities of practice. Yet workforce planning continues to prioritize the number of professionals trained rather than where and how learning occurs.
If health care increasingly happens outside hospital walls, education will need to evolve alongside it. Deliberately expanding high‑quality training sites in community settings would better reflect how and where care is delivered, while exposing learners to the realities of caring for people whose needs are often invisible in hospital corridors.
The challenge before us is no longer whether we can train more health professionals, but whether we are willing to move learning out of the metaphorical “theatre” and into the places where health is shaped and most urgently needed.
