Measurement Is Not Meaning

Bridget reflects on rural emergency medicine research

Like many of you, I worked Christmas in my rural emergency department this year. But between shifts, I managed to carve out some quiet time to re-read an old favourite: John Berger’s A Fortunate Man.

First published in 1967, the book is Berger’s portrait of John Sassall, a solo general practitioner in rural Gloucestershire. It’s often described as a classic of medical writing but rereading it now, in an era of time-based targets and key performance indicators, I found myself questioning the epistemology of research itself. Do our contemporary research methodologies really help us to know what good-quality rural emergency care looks like?

One of the key philosophical questions RRECN has been grappling with is what defines rurality. In Australia, we rely on the Modified Monash Model, based on geography and population size. Berger, however, describes rurality as proximity to power. In his account, people living in Sassall’s community are not remote because of kilometres travelled, but because they are structurally excluded from decision-making, theory-building, and policy formation.

The subjective feeling of remoteness has little to do with mileage. It is a reaction to economic power… ‘all decision-making which is not practical, all theory, seems to most of the local inhabitants to be the privilege and prerogative of distant policy-makers’.

Sassall is trusted, Berger argues, because he lives among the people he serves. Yet his way of thinking and his education could only have been acquired elsewhere. He straddles two worlds: his parochial rural community and his privileged background.

Berger captures Sassall’s practice through a series of vignettes. In one rural emergency scene, a forester is crushed beneath a felled tree. Sassall drives through mist with his hand on the horn so the trapped man will know help is coming, then coordinates morphine, blood, and rescue. This is long before CT scanners or viscoelastic testing.

Toward the end of the book, Berger tries to quantify Sassall’s contribution and fails.

‘What is the social value of a pain eased? What is the value of a life saved? … You cannot expect to evaluate a man’s life’s work as though it were stock in a warehouse’.

For those of us involved in rural emergency research, this feels uncomfortably relevant. We want data, registries, trials, quality indicators and outcome measures, especially in rural settings that have long been invisible to research. RRECN exists because rural emergency care has been under-measured and under-theorised.

But Berger reminds us that measurement is not meaning.

‘I do not claim to know what a human life is worth – the question cannot be answered by word but only by action, by the creation of a more human society…  within its own terms, a doctor who has surpassed the stage of selling cures, either directly to the patient or through the agency of a state service, is unassessable’.

Berger’s evaluation of Sassall is neither qualitative nor quantitative; it is sociopolitical. He asks whether Sassall was a good doctor for his time and place and insists that such a question cannot be answered without examining the structures that shape his work. For those of us involved in rural emergency research, this is a timely challenge. Our work must do more than optimise metrics: it must grapple with uncertainty, proximity, trust, and power. It must ask not only what works, but for whom, where, and at what cost. Berger’s question still stands—how do we take the measure of work that eases suffering, accompanies despair, and keeps going when systems fall short?

---