Gratitude. The emotion a family felt toward the surgeon who had saved the life of their relative. It was the word Adrian Pitts had used more than a decade before after operating successfully on Peter Kronk. He'd asked me if I missed it – the gratitude – since I was no longer a surgeon.

At the time, I'd scoffed at his remarks. I'd always viewed surgery as a job and a successful outcome as both an expectation and the result of a job well done. Talking to the family afterward was merely one of my responsibilities as a surgeon. It gave me no pleasure. If anything, the emotions the relatives displayed – sighs of relief, tears and even the occasional fainting – were unsettling. The whole process made me uncomfortable and I'd typically made my communications with the family as brief and succinct as possible.

Years ago, Louisa and I had waited not far from where we currently sat for word on Peter. At the time, my primary concern was whether I'd done enough in the back of the ambulance to keep the boy alive. I also worried that I'd allowed my dark mood over the practical joke played on my by the locals to cloud my professional judgment. Had I followed up with Peter and diagnosed his condition earlier, there would probably have been no need for the impromptu surgery.

All that weighed on me and, when I learned that Peter would be fine, I felt an enormous sense of relief.

This evening, awaiting word on James, I felt . . . conflicted. As a GP, I knew I'd properly and promptly diagnosed my son's condition. As a surgeon, I knew the surgery was straightforward with minimal possibility for complications or an adverse outcome. As a parent, I was nervous.

My mental clock was ticking and, without looking at my watch, I knew that Pitts should be closing right about now. And Chris Parsons should be arriving at Morwenna's house within minutes. Once again, I railed at my impotence.

"He told us surgery would only take an hour," Louisa said, glancing at the wall clock across the room.

"About an hour, Louisa. Laparoscopy can sometimes take a bit longer than an open procedure."

"You're sure it's safer?"

"It has fewer complications and requires a much shorter stay in hospital."

"So you're saying it's not safer?"

I sighed. Sometimes Louisa flummoxed me. Did she really think I'd have allowed our son to undergo this surgery if there was an alternative with less risk? "The risk of complications is comparable for both procedures and is extremely low."

"Right. Good." A few seconds later, "How much longer?"

"It should be soon."

As if on cue, the waiting room door opened and Pitts – still in his surgical scrubs – strode toward us. We both stood and I felt Louisa clench my forearm.

At the site of Pitts' broad smile, the tension I'd been holding for the past hour instantly dissipated.

"The surgery went perfectly," Pitts said. "No complications at all. They're moving James to Recovery now. Give them a few minutes to get him settled and you can be there when he wakes up."

"Thank God," Louisa murmured.

I half expected Pitts to say, "No, thank me." He didn't.

Pitts had successfully completed an uncomplicated surgical procedure. It's what was expected of a surgeon of his experience. Appreciation and gratitude were unnecessary.

"When will he be released?" I asked.

"Assuming he's able to walk and eat, he should be able to go home tonight – but it will be quite late. I have to admit, if you weren't a doctor, I'd probably keep him overnight. But I'm sure you know what to watch for and what to do if there are any unexpected complications."

From any other surgeon, I would have the comment as a compliment. From Pitts, I knew it was nothing more than a statement of fact.

"Yes," I replied.

We stood awkwardly for a moment – Pitts probably waiting for the gratitude he felt was his due. And I, waiting for him to depart so I could see to my son.

"Well, I'll leave you to it then," Pitts finally said.

By the time we reached Recovery, James was already there. He looked small and fragile in the bed. The expression on his face was so peaceful that, were it not for the monitoring machines that tracked his vital signs, one might be tempted to think he was dead.

I stepped to the bed and touched the back of my hand against his forehead.

"As you can see," the Recovery nurse pointed to the monitor, "his temperature is normal."

Of course I could see it – the machines dutifully recorded it. I simply needed to touch my son, to feel him alive under my fingers.

"He should be waking up soon," the nurse continued. "When he does, he might be confused at first. It's also possible that he could be nauseous or even vomit."

Louisa looked a bit aghast.

"It's all perfectly normal," the nurse reassured her. "Nothing to worry about."

"I'm more than familiar with the potential side effects of general anesthesia in children," I informed her.

"I know you are, Dr. Ellingham," the nurse said pointedly. "I thought the information might be useful to Mrs. Ellingham."

"Yes, it is," Louisa replied, giving me a dark look. "Thank you."

"Just be reassuring when he starts to awaken," the nurse continued. "Help him orient as to time and place."

"Yes, yes," I said impatiently. "I'm sure you have other patients to attend to."

She put one hand on her hip. "James is my patient and it's my responsibility to ensure his recovery is uneventful."

Rather than respond, I pulled back the blankets and lifted James' gown. Pitts had made three incisions of about 2.5 centimeters. Each had been closed with skin glue. They were small and neat and would leave minimal scarring. From what I could see, Pitts had done an excellent job.

I yearned to review my son's medical chart. In years past, I could have simply requested it. Now that charts were electronic, getting access was a more involved process and I decided to defer it until later. Also, what I really wanted to read were Pitts' surgical notes and he was probably still in the process of dictating them.

James stirred in the bed and Louisa was instantly at his side. "James. It's Mum."

His eyes opened, he looked her, seemed to smile, then almost immediately fell back asleep.

"That's perfectly normal," the nurse said from behind us. "It usually takes a little while for children to fully come out of the anesthesia."

I checked his vital signs again, pleased to see that all were within expected values.

The nurse brought in a chair and put it beside the bed. "This'll be more comfortable, love," she said to Louisa. I noted in passing that she hadn't offered me a chair.

When James awakened again a few minutes later, he seemed a bit more alert. His gaze focused on Louisa. At first he smiled and then confusion clouded his features as he took in his surroundings.

"Where am I?"

"You're in hospital," Louisa said softly, stroking the hair on his forehead.

"Hospital?"

"You had an operation. Remember?"

"That's right, James," I added. "You did very well."

The nurse pushed forward and, after introducing herself to James, listened to his chest with her stethoscope. "Are you having any pain?" she asked when she'd finished.

James shook his head. "I'm cold."

"I'll get you some more blankets."

He turned to face me. "Dad, why am I here?"

Across the bed, Louisa looked concerned. I knew that confusion was common in post-anesthesia patients, especially children.

"You had an infection in your stomach," I said, grimacing internally at the imprecise anatomical explanation. "You had an operation to fix it which is why you're in the hospital."

"Oh."

By the time the nurse returned with the blankets, James was again asleep.

Use of mobiles was prohibited in the Recovery area and I needed to call Chris to check on Emma. I took advantage of James being asleep to make my way to the corridor outside Recovery where I could make a quick call.

Parsons answered on the second ring.

"How is she?" I asked.

"First things first," he responded. "How is James?"

"Out of surgery. In Recovery. Awake but not yet fully alert," I responded succinctly. "Now tell me about Emma."

"No signs of concussion," he reported. "Thanks goodness she was wearing a helmet."

"Are you certain?" I persisted. Did you check for blurred vision, photophobia—"

"Mart, she doesn't have concussion. She does, however, have a probable greenstick fracture of the right radius and I put seven sutures in her right calf."

"You splinted the arm?"

"Of course." Chris provided a concise summary of his treatment. Morwenna and Al would bring Emma to hospital in the morning for x-rays of the arm and a decision on whether to cast it. And he'd given Morwenna a list of symptoms to check for during the night. "She has my number," he concluded. "If any issues arise overnight."

I thanked Parsons for covering for me and told him I'd follow up with Morwenna in the morning.

"Mart, focus on your son. I'll be around all night if there are any unexpected complications, and the doctors at Truro will take care of the child in the morning. As good as you are, you're not indispensible to Emma. You are to James."

Parsons was right. Yet, I was still anxious. Ever since I'd come to Portwenn, I'd hated turning my patients over to other doctors as, too often, the results had been less than satisfactory. Tonight, I had to hope that my trust in Chris Parsons was not misplaced.

I thanked Chris and headed back to my son's cubicle. As I passed the nurses' station, I wasn't surprised to find Pitts there, typing into the computer. No doubt he was entering his surgical notes. I gave him silent plaudits for doing so immediately after surgery, while his memory was still fresh. It's what surgeons were supposed to do, but too often they delayed this somewhat tedious task hours or even days.

Pitts looked up as I walked by and tried to catch my eye. "Chief, I was going to come find you. Can I have a word?"

I scowled, trying to decide whether Pitts' calling me "Chief" was his way of taunting me – in effect reminding me that I was no longer a surgeon, let alone a chief of surgery. I decided to meet his challenge head on. "I haven't been chief of surgery for more than a decade."

Pitts seemed unfazed by my correction. "Old habit," he explained without apology. "Dr. Ellingham, then," he added, motioning me toward into a nearby corner, which offered some privacy in this busy ward. I had no idea what he wanted to talk to me about. While it was possible there was something to do with James, I didn't think it likely. I'd already assessed his condition and saw no cause for worry.

"What is it Adrian?" I asked, not quite managing to keep the annoyance out of my voice.

He took a deep breath and slowly let it out. "You don't like me much, do you?"

"You performed successful surgery on my son. My liking or not liking you is irrelevant."

"I learned it from you, you know. How to treat people."

My eyebrows lifted.

"Back in London, you told us it didn't matter whether our patients or even our colleagues liked us; it only mattered that we were good surgeons."

Pitts was right. I had indeed said that to my students when I was chief of vascular surgery. Hell, I'd said as much when I came to Portwenn as the GP. And, years later, I still believed that, as a physician, being good was far more important than being liked. Dr. Sim was popular; he was also an appalling physician. Dr. Dibbs was liked; as a GP, she was an unmitigated disaster.

Patients needed their doctors to provide high quality medical care, not to be their friends. And, while it was fine to be pleasant to one's medical colleagues, the doctor or nurse you wanted assisting in surgery was the one who was the most technically competent. It was even more true in my position as chief of surgery. I had limited time to turn a bunch of green registrars into exceptional vascular surgeons. I did that by driving them, challenging them, and teaching them. I needed their respect, not their friendship.

"And I'm a damned good, surgeon" Pitts continued, interrupting my thoughts. "What's more, you know it. If you didn't think so, you'd never have let me operate on your son." Pitts' tone was matter-of-fact, stating the obvious.

I couldn't deny the truth of his words. But I had no idea where this conversation was headed. "What do you want from me?"

"I want to know why you wouldn't give me that recommendation."

Recommendation? Did he mean the one from ten years ago? When he'd wanted me to talk to Chris Parsons on his behalf? Was this about what had happened when Peter Kronk was still a child? "I don't see what—"

"I want to know. After all these years, I deserve to know. I saved your son tonight. The least you can do is tell me why, knowing I was a top-notch surgeon, you wouldn't do so much as put in a good word for me with Parsons."

Wow. So it was the issue from a decade earlier. Ten years later and it still nagged at him. I'd told Pitts at the time that he was an arse, and that Chris Parsons shared my view. It was true then – and probably still true now, though I couldn't be entirely sure. Ten years ago, Pitts had been a talented surgeon and a despicable human being. At the time, I wasn't willing to see past his personality flaws to give him the recommendation he so wanted.

Personality flaws. I recalled when I first met Louisa on the plane and then at the hotel when interviewing for the position in Portwenn. She'd certainly had reservations about my ability to function as the village GP from a personality standpoint. If truth be told, she'd probably considered me to be an "arse." What if Parsons hadn't intervened and she – and the rest of the board – had rejected me based on my personality?

At some level, I rationalized that Pitts and I weren't alike. I was widely perceived by as abrupt, dismissive or even unfriendly. On the surface, Pitts was none of those things. He appeared quite friendly – especially to those who didn't know him well. The problem with Pitts was that, beneath that exterior veneer, was a certain nastiness, even cruelty, toward others, especially when he felt aggrieved.

I recalled his comment about finding lunch for his girlfriend so she would "put out." And, not long after, he'd exposed my blood issue to the entire village. There'd been other examples such as the time when he'd been shown up on rounds and retaliated by sabotaging that colleague's research experiment.

Plainly stated, it was all about him. Adrian Pitts had disdain for those he considered beneath him. As for everyone else, he tolerated them as long as they helped him advance. He would do what it took to get ahead and, if things didn't go his way, he retaliated quickly – and viciously.

It all made sense to me. Now I had to figure how to explain it to the man at the center of it all – or whether I even wanted to.

"I told you that day why I didn't recommend you," I started. "It had nothing to do with your surgical skill and everything to do with your being an arse."

"So, I'm an arse because I tell the truth? You tell the truth and don't care what others think."

You tell the truth. The same words Peter Kronk had spoken that night. I'd never shied away from telling the truth, even when it hurt. And, I wasn't so dense as not to recognize that sometimes I did hurt others, such as Peter more a decade ago. And Louisa – more times than I liked to recall.

"So tell me," Pitts persisted, "how am I any different than the great Martin Ellingham?"

Pitts' words stung. Did people view me with the disdain with which I viewed Pitts? And, if so, did I care?

Was I different than Pitts or was it merely a matter of degree in the way we treated others? Had Pitts simply taken honesty to the next level? Was Adrian Pitts simply a more strident form of me? More importantly, had I – in expressing indifference to how others reacted to my words and actions – helped create the man he was today?

No, there had to be something more, something that separated us. Louisa despised Pitts and yet she loved me enough to marry me. That had to count for something.

Pitts was staring at me, awaiting my answer.

"The difference between you and me, Adrian, is that you actually set out to hurt people. You take pleasure in it. For you, it's not about being honest, it's about being cruel."

"I don't—" Pitts stuttered.

"That's why," I continued, "I don't like you. And why, even though you're a good surgeon, I didn't recommend you."

Pitts swallowed hard. "So what you just said, that wasn't intended to be hurtful," he said, allowing the sarcasm to show through.

"It was the truth."

Pitts gave me a smarmy smile. "You know, what Mrs. Ellingham said to me all those years ago was wrong. We actually are alike, you and I."

"No, we're not," I said and turned on my heel. As I walked away, I still couldn't help but question the truth of my words.

Medical Glossary

Greenstick fracture – Occurs when a bone bends and cracks, instead of breaking completely into separate pieces. The fracture looks similar to what happens when you try to break a small, "green" branch on a tree. It is common in young children.