Lozon and Fox have provided a thoughtful analysis of Canadian academic health centres. However, their account is incomplete. Their emphasis on the "shared purposes and goals" of the component groups of academic health centres overlooks the profound tensions and disagreements that have always existed between medical schools and teaching hospitals. In addition, their claim that academic health centres "have endured in more or less the same form throughout their history" ignores the profound growth, changing organization and evolving missions that have characterized these institutions for over a century. Lastly, they do not address the most profound dilemma of all of the academic health centres: that current financial pressures are causing an erosion of their educational work. These three aspects of academic health centres are discussed in this commentary.