First, something that needs no further comment. A government report has concluded that those areas of the NHS that were given targets have improved, but areas not given targets have not. Conclusion? We need more targets. The intellectual incisiveness of this impeccable logic leaves me unable to write any more on the subject.

So I'll turn to training. Surgical senior registrars were sometimes in post for 10 years. This made them very experienced, especially when one in two and one in three rotas were the norm. They did the emergency surgery; consultant surgeons were not often seen at night. Ten years in a senior training post was too long. Consultant surgeons are now seen more often at night, and for many it is in their contracts. Making sure that the sickest patients are dealt with by those with most experience sounds a good idea, but actually it's not necessary. What matters is that the sickest patients are dealt with by those with enough experience, and that someone with more experience can be called on if needed.

I think we need to be worried. Consultant surgeons are doing more emergency surgery because their trainees do not have the experience. It worries me that often there is not even a surgical trainee assisting. Letters to the formal and informal medical press document the precipitate fall in the number of procedures undertaken by trainees. They are not doing as much, and they are not getting the variety. Sub-specialist trainees may do enough of their specialist operations, but patients aren't admitted with specialist diseases; they are admitted with acute abdomens, and there need to be enough generalist surgeons around.

This is a problem for all the practical specialties, and probably for all of medicine. The recent clamour for strict syllabuses and competence-based training is all very well, but there is an indefinable something that comes from experience: Michael Eraut termed it ‘tacit knowledge’. It's knowledge that you don't know you've got, so it's not easy to pass it on, other than by being there and doing it.

Firemen, a patient told me, are no longer allowed to set fire to derelict buildings and then go in to put them out. Health and Safety won't allow it. So the only experience they have of big fires – which are rare – is when they are called to one in an emergency. They then lack the subconscious reflexes that warn them a wall could collapse.

Everything has a balance: will it be restored in medical training before it is too late?