Doctors and nurses need to be replaced by computers and robots

http://www.city-data.com/forum/great-debates/2010126-doctors-nurses-need-replaced-computers-robots.html

by spec • 13 years ago

32 55 13 years ago

na852• 13 years ago

No, they really don't.

I'm married to a physician and I can tell you that Medicine is an incredibly nuanced profession, and though doctors and nurses can benefit greatly from computer assistance, they cannot be reliably and safely replaced by computer algorithms. The single data point of Watson diagnosing lung cancer is not enough to generalize over the entire profession and range of ailments.

Medicine is a great deal more than differential diagnoses, doctors are a great deal more than "professional diagnosers", and nurses are a great deal more than morphine dispensing diaper-changing automatons.

Most medical schools (in my country, at least) have moved to an entirely evidence-based and patient-centred-care model years ago. The problem of course is that evidence is not always easily gathered because of ethical issues (e.g. most hypothermia knowledge comes from Nazi human experimentation on POWs and Jews. Also it's hard to conduct a study on OB/GYN topics because you could potentially be putting infants, fetuses, and their mothers at undue risk). Being treated by a computer is not going to change this problem of poor evidence.

That forum post was written by someone who has only a shallow appreciation for/understanding of the field of medicine.

Brakenshire4• 13 years ago

You may well be right, but nevertheless, where medical care can be automated, it should be. Because otherwise medical care never gets more affordable. The economy doubles in size, wages double in the general economy, and ... doctors wages double. As long as we consider medicine an elite profession (so that we don't train an overabundance of doctors and drive the wages down, which most of us wouldn't want to do) employing medical staff will always cost some approximately fixed multiple of the median hourly wage. And medical care is and has always been too expensive to provide proper care for the entire population. If, for instance, we can automate doctors taking blood pressure readings, by giving patients their own sensor, or automate the drawn out process of step-by-step diagnosis by driving down blood cost prices so that 50%, 5% and 1% diagnoses can be explored simultaneously, or have automated machines which allow frail, elderly patients to bathe without needing a nurse, then we can really start to improve care, and decrease cost (which, in any case, will simply be reallocated to dealing with other ailments). Doctors lose nothing, but, step-by-step, the general population gains immeasurably.

eru3• 13 years ago

And medical care is and has always been too expensive to provide proper care for the entire population.

Which countries are you talking about here? (I agree with your general sentiment, though.)

yeukhon2• 13 years ago

Because otherwise medical care never gets more affordable.

They can be affordable but the problem is largely because of the large number of law suits hospitals might have to face, and plus the cost of buying those technology. Then you go with drugs. Those are expensive. Regulations, license, those are costly too.

And salary too, very high. One might argue that doctors deserve to be paid more if they can do the job properly, saving people's life. I won't get into that, but unless you can cut drug $$ down, salary down and law suit down, or at least two of them, you won't get very far from affordable healthcare.

You might ask why isn't Chinese medicine expensive.

bigchewy3• 13 years ago

Almost none of the prescriptions you offer have any measurable impact on healthcare spend. Blood pressure readings -> performed by $18 Medical Assistants Step by step diagnosis -> office visits are < 4% of total healthcare spend etc.

Now, what actually costs money is getting your spine surgery at Stanford rather than the outpatient clinic which costs more than getting physical therapy. It takes a person (often a doctor) to help guide a scared patient towards the most effective option, not the most expensive one. We, as patients, are not experts, so we choose the expensive option as the best proxy for quality. Computers can't engage in a meaningful discussion.

scarmig• 13 years ago

Whether evidence is easy or hard to gather is a red herring. Patients present a body of evidence. Small or large, that evidence is what doctors and machines both use to generate diagnoses. The places where machines have the potential to excel is situating the evidence within a broader universe of evidence.

The human body is amazingly complex, and it's unfair to hold it against human doctors that they don't have the capabilities to use the enormous amount of information we've collected on it so far. Machines do, though, and they're already on the brink of matching or exceeding human capabilities.

It's true that medicine is more than generating diagnoses. But the years of training and huge personnel costs are caused by the advanced levels of knowledge required to perform with competence. The deprofessionalization of medicine means you can substitute expensive labor with much cheaper labor.

There's also the value that comes from standardization. The best human doctors are probably going to surpass machine doctors in their chosen field of expertise for awhile yet. But very few people have access to the best human doctors, and the best human doctor in one area of specializaton is unlikely to be exceptional in areas outside his or her specialization. The proper comparison isn't against the best doctors, or even the average doctors: it's against the worst doctors who make terrible errors in judgment and doctors working outside their area of expertise, whose work will be most easily replaceable by Watson-like software.

na852• 13 years ago

Whether evidence is easy or hard to gather is a red herring.

No it's not, it's incredibly relevant. How can you take an evidence-based approach to newborn and infant care when no studies have been done? How do you run studies ethically on infants who can't give consent? Are you willing to subject a baby to an untested delivery procedure, that could potentially go very very wrong, or would you rather stick with the devil you know?

Patients present a body of evidence. Small or large, that evidence is what doctors and machines both use to generate diagnoses. The places where machines have the potential to excel is situating the evidence within a broader universe of evidence.

Such was my point; that a human doctor or nurse, supplemented with computer analysis, will inevitably be a better care provider than either human or computer alone.

baddox3• 13 years ago

The fact that the discipline is incredibly nuanced is precisely why I want computers doing the heavy lifting, at least when it comes to diagnosis. I find it extremely hard to believe that even the best doctors could come close to touching the accuracy of an expert system. Now, obviously there is still the necessity of a trained and skilled doctor. A doctor should always have the last decision (before the patient, that is), but the doctor should be trained to understand how expert systems work. And of course, doctors and nurses will be needed to gather information from the patient, both through medical tests and verbal questioning.

The fact is, every time I have gone to the doctor for anything other than an obvious diagnosis (e.g. I need stitches in the hand because it is cut and bleeding), I have been appalled at the experience. I experienced fairly serious chest pain at the age of 26, with no history of health problems. I quickly read online about all the things it could be, ranging in seriousness from reflux to a heart attack, and I expected a doctor to have some sort of academic methodology, or do something vaguely resembling science, but instead, they x-rayed me, said everything looks fine, and prescribed me extra strength Tylenol. I wish doctors would at least pretend that they're doing something that a walk-in x-Ray booth attached to a computer system couldn't do.

yeukhon2• 13 years ago

I won't argue that machines can't do amazing things. Technology definitely has helped us to live longer and diagnose more accurately.

I don't have any source to backup my arguments and claims, but for many older medical practitioners, including my family (we have been a medical practitioner for several generations), we feel that the younger doctors lack of confident and knee knowledge because they rely on machines. I have a hard time to put my family's words into English because they are Chinese (they are Western medicine practitioner btw), but the basic idea is that they learn to use their fingers and their sensory inputs to gather empirical information about the patients. I won't say they can diagnose a tumor at a precise location or detect the type of cancer precisely, but experts can diagnose to a very good estimate. Back then they didn't have x-ray in every hospital. Only the major one has x-ray in China and my grandma and my father had to use their fingers to determine the location of the tumor, or the type of tumor. When my dad first saw the x-ray machine back in the 70s when he was still in China, it was amazing to him what he could do with him, but he said practical experiences and hands-on experience matter.

Ask how many new practitioners can do that with confident? I supposed few. Because most of them rely on machines.

What if machine is down? What if the machine is not capable of telling the truth? It has limitation.

I am arguing that machines can't help, but doctors should never rely on machine. They need to rely on their experience and knowledge and this is what distinguish an expert from an average practitioner.

To be honest, getting people x-ray all the time is largely because of suing medical mistreatment and then good part of just being efficient (or lazy if you want to be harsh). Hospitals are scared of getting sued so they'd put everyone through an x-ray machine.

grey-area2• 13 years ago

I wish doctors would at least pretend that they're doing something that a walk-in x-Ray booth attached to a computer system couldn't do.

They are doing more, but won't always feel the need to show their working for minor illness. That doctor will probably have gone through a few checklists in their head, deciding whether this could be a serious illness, and clearly came to the conclusion it was not. Presumably they also asked you a few questions about the location and nature of the pain?

Also, doctors do use computers already, when they're not sure on symptoms, need to look things up, etc. They have the equivalent of expert systems at their fingertips for when that is necessary, but most of the time it won't be.

I find it extremely hard to believe that even the best doctors could come close to touching the accuracy of an expert system.

Accuracy is not what is required, given our extremely poor and fuzzy knowledge of the human body, diagnosis and treatment is more like a tradeoff between different possibilities based on partial symptoms (not all symptoms will be obvious or noticed by the patient), tests which are not always accurate and sometimes harmful, and treatments which are not always effective and have some bad side effects.

An expert system would help with none of the above.

orting• 13 years ago

If an expert system prescribed you extra strength Tylenol would you feel better? I think you are taking a too simplistic view of diagnosis and put to much faith in AI. I have also noticed Watsons good results, but I do not trust them yet, there is a lack of evidence supporting the claim that Watson can make 90% correct diagnosis.

Medical imaging is a big part of diagnosis, especially in many cancer patients. There is a huge effort to automate the segmentation of tumors, and even though algorithms often have higher inter- and intra-observability agreement than radiologists, they often fail miserably for "non-standard" tumors. A fully automated system that scans the patient, make the diagnosis and treatment plans and provides treatment is very far future.

A completely different issue is that the specific combination of a highly developed brain and opposable thumbs are sometimes necessary. Consider cardiac response teams in hospitals, but also general patient care where the ability to fluff a pillow can be just as important as placing a quick IV drop.

vacri4• 13 years ago

I can't see the part in your story where you found out what the chest pain was and that any form of diagnosing entity [sh|w]ould have picked it up.

ghshephard2• 13 years ago

Interesting you bring up the chest pain scenario. In 2003, when I was 32, I had crippling chest pains, and, simultaneously, (this is what scared the crap out of me) my entire left arm went absolutely numb - I was certain I was going to die of a heart attack, and so I immediately called Kaiser (in hindsight, 911 would have probably made more sense, but I was overly sensitive to calling 911 for anything other than murder in progress, somebody not breathing, or house on fire).

I was patched through to an intake nurse, described my symptoms, and she asked a grand total of three questions:

"Are you having any shortness of breath" "Do you feel any nausea or light headedness" "Can you press your fingernail on your left hand, and tell me how quickly it goes from white to red"

After I answered those three questions (No, No, right away) - she then said, "It probably isn't anything, but we'll want you to come in some time this week" - and set me up for an appointment a couple days later.

Total interaction time - less than 5 minutes, and that was with an intake nurse, not even a doctor.

Clearly, an expert system had done the assessment, and had decided, based on some baysean weighing (32 year old is almost certain not to be having a heart attack) plus a few expert-tree questions, that it wasn't really an emergency.

(As it turned out, I was starting to suffer from some RSI in left arm - Doc made the assessment in 90 seconds of prodding my arm, suggested an ergonomic keyboard and less typing - His analysis of the chest pains were, "Likely stress related, nothing to be worried about.")

BTW - my doctor didn't even suggest x-rays. Just a standard stethoscope/Deep Inhale test. When I asked a physician friend of mine later, why they hand't run any tests, his answer was, "You weren't in pain when you visited, had no trouble breathing, - there were no obvious indications of distress, you are 32 years old - there was very low return on running tests, and doctors (particularly at HMOs) are taught not to engage in "fishing" (testing for the sake of testing)

zone411• 13 years ago

You are overestimating the skills of an average doctor. I'm sure your spouse is very skilled, but there have been other success stories facts besides lung cancer when it comes to the diagnosis and treatment http://arxiv.org/ftp/arxiv/papers/1301/1301.2158.pdf: "The results shown here demonstrate the feasibility of such an approach relative to human decision-making performance. Even in its early stages of development, such an AI framework easily outperforms the current treatment-as-usual case-rate/fee-for-service models of healthcare."

I'm not sure what the difficulties in gathering additional evidence do to support your argument? The doctors have huge difficulties even with following explicit guidelines and existing studies.

discreteevent• 13 years ago

I agree. I think this is the same kind of narrow minded mistake that AI made by focusing on getting computers to play chess instead of realising that the hard problem was really building something that could even recognise a single chess piece in different lighting conditions.

A lot of medicine is about perception. Obviously there is a huge amount of physical perception and pattern recognition but also, for example, a brilliant doctor who is not from the same culture as the patient will often miss something vital when taking a history from that patient that a local doctor will pick up straight away. These things are complex and subtle. We need to recognise just how limited technology is if we ever want to really improve it instead of getting too exited about the things it can do.

pinaceae• 13 years ago

absolutely.

case in point: automated call centers. so much better than a human being. instant recognition of what i need, how to help me - simply awesome.

i can see it now - press 1 if you're stomach hurts, 2 if your leg hurts ... OPERATOR!

machines work great when steering and diagnosing other machnes? the fuzzy and subjective human condition? not so much.

EGreg2• 13 years ago

I hear people saying that medicine can't have doctors be replaced by computers and it's more of an art than a science. I'd like to get more information and see why they think that and if their reasons really hold up. It intuitively seems to me computers can do a better job. Here are a few reasons:

1) When you think about what a doctor does, they use a combination of their memory, experience, knowledge and judgment.

2) Computers can remember a lot more relevant facts and wonmt forget them.

3) A doctor's experience is just with their own patients and what they hear at conferences and the literature they read. A computer network can literally aggregate experiences of many different doctors and cases around the world. A new superbug coming out, for instance, may have a treatment that few doctors know, because it's more prevalent in another country -- but a person using the network will be made aware of this treatment. The network will have much more experience than an individual. It will aggregate the outcomes of many therapies and studies.

4) The knowledge of the network can be extracted from the experiene and be much more extensive. Both beause the experence is extensive and because various methods of statistical analysis can be employed. A doctor isn't going to sit there and cross reference worldwide statistics on the success of using remedy X given factors of race, gender, age, etc. The computers can.

5) Finally, the judgment. Here is why the computers can beat a doctor's "gut" overall. They can cross correlate the knowledge from all around the world and find the most major factors. Then given the symptoms, race, age, location, etc. they can suggest the possible diagnoses given realtime epidemiological statistics and the additional tests that need to be done to establish which diagnosis is most probable. In many cases this establish a path to just one diagnosis with statistical accuracy exceeding what one doctor can produce. It can also list the next several possible diagnoses and the tests to establish them. After the diagnosis is established, it can find the therapies along with risk factors gleaned from all the relevant outcomes from around the world.

And this is just for conventional medicine. When we get into genetic therapies, computers and information science will become a huge part of medicine.

zarify3• 13 years ago

I tend to agree about the accuracy of diagnoses when the data is good.

Here's the 'but':

I think my main reason for distrusting computer diagnosis is that computers are still pretty terrible at figuring out what we are telling them, and patients are also pretty terrible at describing what symptoms they're suffering from.

It's all very well to aim a camera at some sort of visible symptom, but what happens when there's nothing there to match against a library of exemplars?

(For comedic value, the data entry panel from the hospital in Idiocracy: https://s3.amazonaws.com/lardbiscuit/pix/idiothospital.jpg )

EGreg2• 13 years ago

Of course we will still need a doctor to perform the tests. But they'll be relying much more on the apps to suggest to them what tests to perform next. The patients won't be telling the computer anything, esp the unconscious patients, and photos won't be analyzed by computers. Idiocracy was a cool movie :)

bigchewy3• 13 years ago

You've hit a minor portion of what a doctor actually does, the differential diagnosis.

At my last business (in sleep medicine), we learned that our patients who met their long term respiratory therapist (RT) before their differential diagnosis had a 20% higher adherence rate than patients who met their RT afterwards.

Concentrating on the Dx is a common desire of the bay area crowd but the reality is we value human relationships. A computer with the best differential diagnosis capabilities will under perform a reasonably competent doctor with empathy simply because patients are more likely to adhere to the prescribed treatment regimen.

now, augmenting doctors with additional information is a different story. I've spent the last 10 years of my life working on that problem.

PavlovsCat• 13 years ago

the reality is we value human relationships

that reminds me of this:

We don’t utilize EMR at the Surgery Center of Oklahoma. Partly due to patient confidentiality concerns. Partly because every operating room I’ve ever been in that has computer capability results in a nurse with her back to the surgeon and patient, typing constantly. Not good patient care, in my humble opinion.

http://032a410.netsolhost.com/WordPress/?p=275

vacri4• 13 years ago

There's factors you're completely missing. One of the things doctors do is ferret out information that the patient doesn't volunteer - they socially manage the patient to divulge information. Until we have diagnostic computers that can pick up on non-verbal cues and other such nuances, we'll have doctors.

ghshephard2• 13 years ago

On the flip side - I'm a helluva lot more comfortable divulging sensitive information to an expert system than I ever would to a doctor.

dagw2• 13 years ago

I think we need two classes of doctors. One that is a diagnostics and medical computer systems experts and never actually meets patients and one who's main focus is human and social skills that actually talks to patients, gets the data to feed into the computers and then interprets and explains the results.

gfodor• 13 years ago

Of course, they won't be replaced anytime soon, but will be augmented via technology, just like the rest of us. Hopefully sooner rather than later. Every field is disrupted by software in the same fashion: massive resistance where practitioners claim the human element is crucial, then of gradual swapping out of manual for automated where it helps, to in the long run largely automated.

I see a big parallel here with education: I am related to teachers and of course they will swear up and down that hand-crafted, personalized lesson plans are key, and teacher-student interaction invalidates the need entirely for automation. I'd imagine in the long run 80% of these "only humans can do it" tasks will be shown to be performed better by expert systems and data-driven algorithms.

Of course the catch is that nobody wants to be told that a large part of the skills they've developed over a lifetime have been made obsolete or relatively worthless through some code and electrons. Software engineers, and many engineering fields in general are used to the idea that every 5 or 10 years most practical knowledge is obsolete, that computers are relentlessly automating things done manually just a few years previous, and to not fight it but embrace it and try to leverage it. I don't think this is a common mentality for most professions. Even physicians for the most part, unless they work in an academic institution, let their reading fall by the wayside and develop habits and ritual around what they were doing when they finished residency.

zarify3• 13 years ago

I'd agree about the parallel with education (I'm a teacher and a number of my family are doctors). Both are fields where the metrics for success (lives/gets better/graduates/etc) come along a road paved with soft skills.

I'm not too interested in getting into (yet) another argument over automating education (or medicine), and I agree with you about the long view on it, but I really do think that it's going to be a lot harder than many people with a "let's solve it with technology!" point of view would like to think (and I came into education with this exact mindset.

jastevenson• 13 years ago

Other posts by this author:

"Programmers need to be replaced by computers...no more buggy code!"

"Lawyers need to be replaced by computers--no more sleazy ambulance chaser ads!"

"Money needs to grow on trees! No more financial problems!"

Suncho• 13 years ago

I know this is sarcasm, but law seems like a great candidate for automation. The law is literally a set of rules. And in the process of automating legal stuff, we might be forced to clean up some existing instances of ambiguity and vagueness. Wouldn't that be nice?

Regarding programmers, much of their job already is to replace themselves with computers. Once a task becomes routine, you should automate it.

Regarding money growing on trees, that's not going to happen in the literal sense. But perhaps the only way to provide for everyone is to institute a universal unconditional basic income. Without jobs, people won't be able to "earn" their livings anymore. But that's okay. They'll be free to spend their time doing things that only humans can do and that nobody may have ever thought to pay for.

How many geniuses out there are spending their time being doctors and lawyers? How many of them will generate the next innovations that propel the human race forward once they're no longer trapped spending so much time at work?

There's only one way to find out!

crdoconnor• 13 years ago

I know this is sarcasm, but law seems like a great candidate for automation. The law is literally a set of rules. And in the process of automating legal stuff, we might be forced to clean up some existing instances of ambiguity and vagueness. Wouldn't that be nice?

Lovely. Unfortunately, most of the practice of law is arguing over its interpretation.

If we can automate product management (giving vague instructions to a computer that can figure out exactly what you want from it), we can automate law.

vacri4• 13 years ago

The law is literally a set of rules.

And when you implement them as a simple set of rules, you end up with ridiculous outcomes. The politicians who make the rules don't (and can't) cater for corner cases. "The law is a hammer, not a scalpel"

lignuist• 13 years ago

Just imagine a robot holding your hand while you are dying.

Gatsky2• 13 years ago

I'd like to make two points.

Firstly, before anyone builds an AI that can look after people, maybe they can fix the software for looking at Xrays WHICH ALWAYS STOPS WORKING IN THE MIDDLE OF A BUSY CLINIC.

Secondly, I challenge someone here to put a number on how much it would cost to produce an AI that can operate robustly in a clinical environment. This includes the costs of developing such a thing, deploying it as well as testing it. Testing it would arguably be one of the most difficult and complex software testing problems ever. Now whatever that number may be, I hazard to guess that it's a lot. So what you are proposing is to spend a lot of money, so that we can practice medicine... slightly better... MAYBE slightly better.

The greatest improvements in healthcare come from the development of novel therapeutic technologies (antibiotics, vaccines, anaesthesia) or public health measures that change behaviour (sanitation, seat belts, quit smoking campaigns etc).

All of this frankly makes me sceptical of the wisdom of spending zillions on building medical AI, even if such a thing were possible.

Brakenshire4• 13 years ago

I think in some ways we're thinking of automation in the wrong way. That doesn't have to mean having having an AI doctor, with, you know, a lovely bedside manner. Reducing the cost of blood tests so that you can do a sweeping diagnosis of 50 problems at once rather than just 10 is a sort of automation - the doctor no longer has to carefully navigate their way through "there's a chance that it is this, but the blood test is expensive, so we'll try something else first". It's automation to analyse blood tests in combination, and look for profiles for diagnosis. It's automation for a patient to have their own smartphone-connected blood pressure monitor, which will alert the surgery if the read-out is dangerous. It's certainly automation to use software image analysis to pick up the presence of cancer cells in tissue biopsies. It's a step-by-step process, it doesn't have to be all at once.

krakensden• 13 years ago

Want to work on any of the above? Bio-Rad is hiring in the Bay Area.

Gatsky2• 13 years ago

As other people have commented, augmentation is a very good idea, and automation is part of that. The title of this submission indicates something entirely different to that however.

As an aside, the really interesting part of image analysis is not that we can automatically detect tumor cells, but that machine learning can extract features from pathology specimens that a human could never see:

http://www.ncbi.nlm.nih.gov/pubmed/23100629

aeberbach• 13 years ago

I feel like a sucker for responding to such obvious self-serving link bait, but full of gratitude to the very human staff at the hospital where I had a minor procedure last week I will anyway. Here's the simplistic refutation that is all the simplistic premise deserves:

Until you pass a Turing AND a Voight-Kampff test, stay the fuck out of my health system.

zackbloom• 13 years ago

Medicine is no longer an intuitive game. The best results come from following rigorously tested algorithms, not intuition. Research, on the other hand, is where the creativity is and that should continue to be done by humans.

bigchewy3• 13 years ago

source?

lostlogin• 13 years ago

I work on a supposedly state-of-the-art GE scanner. If I let it select parameters it wants there are real, measurable negative consequences. It is a buggy, bad piece of hardware. Sure, there are better machines out there, but codifying the processes the human operator has is not going to happen anytime soon I don't think - hell, GE don't know how to get a user selection of a bool parameter right (it has a text field for the user to type in 1 for on, 0 for off. No toggles, buttons etc). Still, the craptastic system spurred me to learn a bit of coding to make stuff happen that the scanner can't/won't do. Don't rush in to replacing the humans too soon.

BadassFractal• 13 years ago

At the very least we can get started by having doctors be thoroughly assisted by computers. Transition from humans to full automation is always difficult, so it's good to start with the computer being a very accessible and very powerful resource that helps inform the doctor's decisions through data.

lifeisstillgood• 13 years ago

Enhanced by, assisted by, supported by, reminded by, taught by - yes, sure

Replaced by? Do me a favour.

otikik• 13 years ago

Simplistic article to say the least.

vacri4• 13 years ago

Ha! Nurses need to be replaced by computers and robots? The only mention of 'nurse' in the rant is 'the uniforms carry bacteria'... because a robot wouldn't? Every surface in a hospital carries this stuff. I'd like to see the pricetag on a robot (or range of robots) that can do all the physical skills of a nurse, let alone the social management.

I remember having to hold onto a patient's leg for a nurse to put in a needle in a tiny vein in the foot, as all the others had collapsed. The patient was in an altered conscious state and was moving around - I was keeping the leg relatively still. I'd like to see a robot succeed that task without being explicitly designed for that exact use case. It would be genuinely impressive.

bobowzki• 13 years ago

I'm a physician and software developer.

Diagnosing is a actually a rather small part (but very important) of my daily job as a physician. Doctors can't be replaced by computers and robots at the moment because much of what I do is listening, comforting, reassuring, educating, managing, administrating etc etc.

We urgently need better computer support tools. Will doctors be replaced my robots? When you feel comfortable being comforted by a robot they will.

Doctors and nurses need to be replaced by computers and robots

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