Rationalizing medical work. Decision-support techniques and medical practices, Berg, M., Cambridge, MA: MIT Press, Inside technology series, 1997, x+238 pp. ISBN 0262-02417-9

Reviewed by Eric Monteiro, Dept. of computer and information science, Norwegian Univ. of Science and Technology, Trondheim, Norway (eric.monteiro@idi.ntnu.no)

At first glance and judging by its title, the book seems to deal with decision support and expert systems. Although medicine is among the last of strongholds, this has been a radically declining information systems research genre since the mid 80s craze. Decision support systems as such have today a relatively confined role with moderate repercussions for our field as a whole. To categorise the book merely as a contribution in this restricted area would, however, be a serious misconception. The real contribution of the book is due to the way it analyses how information systems are – really – used. In this sense, the focus on decision support systems is fairly instrumental. The most fascinating and novel aspects of the book is the way Berg discusses the simultaneous transformation of the tools and the work during a process of appropriation.

Berg situates his study in a broader context of fundamental changes in the health care sector. He demonstrates in chapters 1 and 2 how attempts at introducing decision support systems should be recognised as an expression of a much broader, historical ambition of making medicine and medical practise more rational and streamlined. In short, to transform it from "art" to "science". The focus on decision support systems accordingly functions as a convenient lens into a broad institutional and political restructuring of medical work.

The empirical basis of the book consists of three different types of decision support systems: ACORN, aimed to support decisions about the treatment of patients with chest pains, was a hybrid system partly based on statistical inferences but supplemented with symbolic rules; de Dombal’s tool, a statistical inference tool aimed at treating acute abdominal pain; a research protocol, i.e. a detailed, standardised set of conditional recommendations, to treat patients with locally advanced breast cancer.

A core theme in the book, drawn from the close affinity with the line of thinking found within the field of Science and Technology Studies, is that there is no clear-cut boundary between a formal tool (like an information system) and its users and their work routines. For decision-support systems, this implies a critique of those arguing for the need to identify formalisable pockets of medical practise. It is rather, Berg argues, an issues of how domains get made formalisable, how the tool and the domain of practise are simultaneously disciplined and aligned to each other. For information systems more in general, the transformational logic is a critique, as Berg elaborates convincingly, of a prevailing conception of how systems do (or do not) "fit" with existing work and routines. To make an information system work amounts to a process where both the tool and the practise are negotiated and disciplined to each other. In this process, both are transformed hence producing a new situation that cannot be reduced to any simple combination of neither the tool itself nor the practise prior to the tool.

Berg argues that a lot of the work within CSCW has neglected this transformational potential. The massive import of ethnographic studies, resulting in detailed and complex accounts of work and the use of technology does (unintentionally?) produce an impression of practise as something too fragile to be touched. All interventions, including development of information systems, are bound to upset the finely tuned balance of existing practise. The book is organised to emphasise this simultaneous transformation of both the tool and the practices. Following the first chapters devoted to historical changes in medical work, chapters 3 and 4 focus on how the tools get transformed while chapters 5 and 6 focus on how work and personnel are transformed.

An essential aspect of Berg's argument, again perfectly in line with work within Science and Technology Studies, is that neither the tool nor practise should be conceptualised as monolithic entities. Rather, they are heterogeneous networks of practises, people, habits, tools and routines. The aligning of a tool with a practise is accordingly not the disciplining of two singular entities, but the interlocking of two comprehensive networks. An interesting aspect of this perspective is the way it lends itself to a critique of viewing information systems as tools. The notion of a tool, Berg argues, implies a high degree of control: man controls his tools. This sense of control evaporates when tools and practises are recognised as networks too comprehensive to control as "neither the tools nor the personnel can be said to be in control. Rather, control is distributed among them in intriguing and poorly understood ways - and it is in this distribution that the power of the resulting hybrids lies" (p. 124).

An effect of the perspective on the limits and scope of formalisation, is a refreshingly non-dogmatic approach to the topic of standardisation. Standardisation, an absolute prerequisite for extending the scope and reach of information systems across multiple sites and communities, has often been hampered by rather dogmatic concerns for the necessary abstractions and simplifications involved. As alluded to for CSCW, the detailed accounts of the different situated, contextual sites seem to ban the possibility of standards that cut across unique contexts. Berg's approach, however, is to pragmatically explore what is gained and what is lost (and for whom) by establishing standardised practises and protocols.

Berg's perspective has a lot to offer critically, yet constructively, inclined efforts of establishing working information systems. His trajectory of a steadily higher visibility in the IS research community ought to be a sound platform for pursuing the slightly programmatic aspirations for involving himself also in design. Berg's work can be seen as an invitation to explore the uncharted terrain of establishing new, technologically based practises - without leaving behind the methodological and analytical tools of detailed, rich accounts of human activity. Come for a ride!