Welcome to you stuff you should know from house Stuff Works dot com. Hey, and welcome to the podcast. I'm Josh Clark. There's Charles W. Chuck Bryant. Our guest producer Noel is here. Yeah, Jerry needs a buffer day from her Christmas break. I can't say that again. No, she's at home on her buffer day. And the freezing cold because we record these somewhat in advance, we are in the midst of the polar vortex and um, yeah, everyone's just talking about how cold is We're back. It is our first recording after the holidays. It's literally freezing cold up. So welcome back, buddy, Thanks, Welcome back to you too. Even though this will be what like late January, it will be a balmy sixteen Atlanta. I think the end of the end of January is when this one comes out. All right, Well, happy New Year, and happy New Year to YouTube, and happy holidays to you. Thanks. Um Chuck, Yes, sir, you're feeling good. You're loose, You're ready. I'm loose. So you see this. You've seen this before. Yeah, you're fit. My fit bit is that buzz marketing? Not really, It's just a really good example. Um I've felt like Fitbit, I'm not like necessarily loyal to it or anything like that. They don't pay me money to mention the podcast. Sometimes it's be like, stop staring at me fit Bit. Um. But no, I like it. I'm happy with it. Um. I I pointed out though, because it's part of this to me, and I don't think it's over confirmation bias. It seems like there really is a growing desire among just average ordinary people to be able to track there their health, their well being, their activity, um, and to do it easily. Yeah, we have tools now that make it, like that thing super convenient. Yeah, it's and Fitbit's not the only one. There's like Nike fuel Band. There's Jawbone is another really good one. There's others like um that track uh, your galvanic response, so they're able to put that together with respiration and heartbeat and come up with a pretty good assessment of how many calories you're burning at any given time, which is like kind of a holy grail with this kind of thing right now. Um, there's others that check your sleep. There's apps out there that let you um check your mood. Um. There's sites like Quantified Self which are basically like people trying to push wearable technology like this further into the future. There's entire websites like share care dot com that are dedicated to health information and health um uh support self advocacy. Yeah, and there's this. It seems to me, this desire to kind of say, hey, this is my health, this is my body. I want to know more about it, you know, like I don't want to necessarily cut out doctors, but I I I want to decide if I should go to the doctor, if it's time or not, and I want to use data to do that. Yeah. I imagine U. I frustrate a lot of doctors because I'm one of those obnoxious people that goes in and it's like, well, here's what I think I have based on my research. There's nothing wrong with that. Yeah, that is what you're an informed patient. That's true, exactly what you're supposed to do. And if you're getting on your doctor's nerves, then go see another doctor. Yeah, I agree. Actually in search of a new GP right now for those because and others you got on his nerves other reasons too. Really cold cold hands like poor bedside man are never seen the doctor, like here's my intern from Emory. Yeah, which great. You know. I love them getting experienced, but I would like them both to be in there, not just like smell you later and the doctor leaves. Well that's another thing too. It's kind of like, um, doctor, okay, let's let's just lay it on on the table here. Yeah, what what you've just mentioned and what I was talking about. If you put it all together, the medical field physicians in particular, are currently in a what's the beginning of what's possibly a really pickle of a state for them. I think a transition period, yes, but they may be transitioned right out of existence in large parts. Yes, some may for sure, depending on who you talk to. There's like this whole question now, like what is the future of medicine and more specifically, in the case of this episode that we're talking about, do human physicians factor largely into that future? And the answer is I don't know, yeah, depending on who you ask, Like I said, um, we there's this one guy, Dr Kent Bottles, who um he feels that GPS might go the way of the DODO and be replaced by diagnostic computers, maybe with avatars. Then there's other people like Farhad Manjou's a technical writer, his wife as a pathologist. He thinks, no, no no, no, the gps are the ones that are going to be in business. The specialists are gonna be out of business because computers are really good at specializing on one single thing, not maybe so good at a general practitioner thing. So there's lots of opinions out there on how much they'll be replaced and who might be replaced. Right then, As Reclined wrote a column who basically he basically said like no, like we we will still need humans, but we mainly need humans to communicate to the other humans and facilitate the the interaction between the robots and the humans. And we already have this. They're called nurses or nurse practitioners. Yea. But he kind of as Reclined is the one that thought that a computer avatar might have a better bedside manner than a doctor. Well, let's give that one example. There's this, there was there's an example I kept finding while we were doing research for the sentence. Actually in the article on how stuff works. Um, it's uh. There was a kiosk, a medical kiosk, during a panel called man Made Minds colon living with thinking machines. When there's a colon in there, you know it's serious stuff. Um. And it was at the World Science Festival in two thousand eleven, and basically this, this computerized avatar UM interacted with a woman whose baby had diarrhea, and the woman said, hey, Avatar, my baby has diarrhea. What are you gonna do about it? And the avatar said, well, tell me all the symptoms and all this stuff, and avatar decided that the baby's diarrhea, while present, wasn't severe enough to warrant immediate medical attention, so it went ahead and made an appointment with a human doctor for later on that week. And the mother said that she preferred the treatment by the avatar to the real life nurses at the hospitals where she lived in New York. Yeah. Uh, so it is possible to create computers with better bedside manner than say, your g P. Well, it's at the very least it will be consistent. And that's one of the things that I'm not poopooing. Doctors or nurses are many, many, many, many great ones, but I've also had some pretty bad experiences, as in emergency rooms and with doctors and nurses with a computer. At least it's a consistent you know, their program to display empathy no matter what. You know, they're not too busy and they're not you know, having a bad day, so they they don't you know, they don't have any prejudices against you personally or anything like that. They're a computer. They don't hate diarrhea. But humans, humans respond to even programmed empathy, even synthetic empathy from a computer. I could see that a little bit. Like I've dove into the gaming world enough to know that, you know, the realism of a of a avatar can be convincing, and it's not like you think, oh, it's a real person, but it helps to put a human face on it, you know, exactly literally. Um, they saw a reference to a study that found um, people who are being treated for anxiety disorders tended to share more about their experiences and themselves with an avatar them with a human psychiatrists. Oh that's interesting because they're like not embarrassed to tell a real person. Yeah, that makes sense. I might open up more to to a computer. Right, So so we've got that part, like the bedside manner, it is possible that we can create machines now and are creating machines now that have at least equal, if not better bedside manner than some physicians. Yeah, okay, so bedside manner one of the big things that doctors bring to the table. Check computers have that. Yeah, it's it's different now than it was in the old days. I feel like just the whole quality of personal care is gone down. It's not necessarily the doctor's falts. There's a lot of reasons to place the blame, but it's not like when you were a kid and you feel like you had your family doctor who knew you, maybe even gave birthth you're my son exactly. Um, it just invested like you gotta stick with the same doctor if you want that kind of care, I think, right, And is another benefit besides bedside banner um that comes with that that kind of care, that kind of personal care is an awareness of your medical history. Not just that but oh well, your dad died of congenital heart disorders like that, so you may be at higher risk of it. To just that kind of awareness has been typically lost too. Even though we have medical histories and they're in our charts that they're in our files UM, and intimate knowledge of a patients UM medical history is pretty much lost in today's modern practice of medicine. UM. That's another thing that that computers could conceivably top doctors on UM, which basically falls under the umbrella of diagnosis or diagnostics. Yeah. I mean there's two two sides to this. There's diagnoses and treatment and some UH programs. A little bit of the history this UM goes back to the nineteen seventy is at the University of Pittsburgh. They develop software to diagnose problems. UM. MASS General since the eighties has been working on their d X plan, which provides ranked lists of diagnoses, whereas the what's the computer the Watson Watson who who won a Jeopardy Yeah, that's more based UM. It looks like on treatment options than diagnosis at this point. So well, yeah, but they said it's not They haven't. I don't think they want to leave it alone with diagnosis yet. No, and to do its thing there there's already something out there for diagnosis that's meant to support physicians. From what I understand with Watson, if there is a doctor of the future, it's Watson. Yeah. UM, he has a lot of advantages over not just um human doctors, but other artificial intelligence healthcare machines. I guess you could clumsily call he has a knack for natural language. So let's say there's like a structured formula or formulaic type of language that the medical field is supposed to use, right, yes, okay, um, health records don't always necessarily contain that language. They might contain natural language, which is really confusing for computers to take in an absorb. Yeah. You know, humans can pick up on meanings of things that robots and and software cannot, like inferences, and we might be using sarcasm, although there's probably not going to be any sarcasm in your medical records. Yeah, but like figurative language and stuff like that. But computers a language is a big part of the problem. Or more to the point, with the diagnosis, patient says he feels like he has a hive of bees in his stomach. Like that might mean something that you or me, but to a computer it's like followed the two bees or something. Right, Watson has the advantage of saying, Okay, well there's a sensation of bees in the stomach, there's not actually bees in the stomach. So let's figure this out then, Watson or anything that that he eventually becomes. UM, Well, we'll be able to go through medical records, current medical research, UM, the patient's medical history, uh, diagnostic tests that were done, blood work, instrument tests, and put it all together and then spit out a list of diagnoses with different confidence levels. So the one at the top is the one that Watson says is he is ninety eight point percent sure is what's wrong with this patient? And UM as a diagnostician, that's pretty impressive. And that's using all the available data that's that's available also to human physicians, but they simply don't have the time to make it all in. Yeah. I think some research said that eighty percent of doctors spend less than five hours a week reading medical journals a month a month. Yeah, so that's these things can read thousands in seconds. So it's it's sort of a matter of of efficiency really, and like if doctors don't have time to read all this stuff, I know, we we looked into this one. Uh sort of a savant diagnoser is that a word? Diagnostician? Uh? Doctor uh Dolly Wall in San Francisco. He's sort of legendary for diagnosing things, to the point where he does it on stage as almost like a parlor trick would do. They give him forty five minutes and and a bunch of symptoms basically like really confusing because they're trying to stump him, and generally he comes out on top. But he even uses a program, a diagnostic program called Isabelle. Right, that's the one I said every here that's already here. So doctors are using these to help themselves out. But he says that he's never had Isabelle offer a diagnosis that he has missed. Right, But he's like the dude that yeah, And he also admits that he's like like I'm a freak of nature. Go ahead, quiz me exactly. He also reads like case histories, like for fun, that kind of stuff. He's not, he's not a normal physician. He's a complete and total outlier. Um, if he were. If every physician were like this guy, then they're there probably wouldn't be this conversation going on right now. But most physicians aren't. And it's not just with current medical research that they're just not aware of because they haven't had time to pick up the lancet the last few months, but it's also their training to Like, if a doctor is in practice for twenty years, the brain, and the human brain tends to create habits because it likes to expend as little energy as possible. It's it's trying to be as ficient as possible. And I think the same thing happens with medical practice. You're trained, you understand, you come out of medical school with a lot of book learning, and then you put it to practice and you kind of find your niche and along the way you forget a lot of the stuff that you haven't done in twenty years or haven't learned about in twenty years. So it's not just current stuff, it's old stuff too. And if you feed the physician's desk reference into Watson or one of his his compatriots, like all of that knowledge can be quickly index and research to try to spit out a more accurate diagnosis. Yeah, I think that's a great idea. It's like a partnering up with computers. It is sarily replacing, but what they're doing with Watson is is very much moving towards replacing doctors in that sense. Well, here's a scary stat um one in five diagnoses in the United States are incorrect or incomplete one in five and a lot of times. It's not that the doctor's a jerk or not any good, but like you said, they just maybe haven't seen these cases that were written about in some obscure medical journal that the computer has scanned an index. Ya and Dolly Wall Dr Dolly Wall himself at Freak Diagnostication Dollywood, Yeah, pretty close, which is a wonderful place. By the way, um Dr Dolly wall Uh himself says a lot even with me, A lot of it is intuition, and intuition can be wrong. That's a criticism though, of computers as doctors. They lack intuition. Like there's kind of even a larger even larger than this computer's replacing doctor's conversation going on. It's kind of a conversation or a debate over whether intuition or data. Yeah, Trump's one or the other. Which one is the right way to go? Yeah? This one step too, it says according to an expert, I'm not sure what that means. That sounds sinky, but they said, only of the knowledge of physicians use to diagnose is evidence based, so that means intuition, which which also jibs in dovetails with that one in five being wrong or one in five being right. I'd like the idea of intuition to a certain degree, for sure, but there's also got to be like data backing it up. Sure, you know so in your perfect world. Then it sounds like we still have physicians, but they go back and double check themselves using a program. Yeah, but I could also be down with um simple what is it? What do they call it in here? Um? Something based diseases, rules based chronic diseases. Yeah, like minor things that are pretty easy to diagnose, so they're not even necessarily minor. We just understand them so fully that we say type two diabetes is going to behave and present itself like this. Yeah, but I wouldn't mind going like it seems like once a year I get, like an upper respiratory infection. It's been three or four years in a row, and I know what the treatment is, I know how it feels. It would be great to go and to a machine and have them take some stats and blow into it and hear my wheezing and give me a a steroid shot and a Z pack and a breathing treatment and send me on my way. So it's always what clears it up. Would you care if it was a robot that gave you that shot? Not at all, um, but I definitely would want more personal care if it was something. What if it was a robot with a nice avatar, sexy avatar or just a friendly one. Yeah, that was a little, a little, a little it would touch your forearm here there. Yeah, well that might be a little creepy. Yeah, it's like it was an old timey doctor who like gave you some epocac if you had diarrhea, just send you on your way, drink a coke. But it wouldn't send you on your way to give you ip acac and then it wouldn't let go of your forearm. Yeah. Well, surgical robots, that's a that's a thing. I mean, we're getting around, but they've been performing they've been performing robotic surgery since the early eighties. Um doctor assisted until two thousand ten, where they were in Montreal. They performed the first fully robotic surgeries when they removed a prostate with the fully robotic UH surgeon and fully robotic anentusiologist Dr mc sleepy Dr mc sleepy. Yeah, and then that's the real name the robot surgeon was da Vinci, which is like the basically gold standard for robotic surgical or surgical robots. Yeah, they had in two thousand, thirteen fifty thousand robotic surgeries performed in the US. So it's it's big and um. But the da Vinci is a doctor basically sitting in a little uh it looks like an arcade game and using um robotic arms to mimic his or her movements on more microscopic levels. Right, So the robot has more precise movements and can make smaller movements, um than the doctor. It's tell it's and what's the opposite of telescoping, like going downward in scale? Whatever that is. It's taking the movements of the doctor and reducing them in scale. Let's call it reverse telescoping, reverse telescoping those movements, um, which is a pretty awesome achievement in and of itself. That doctors being fed three d um graphics of what the robot is seeing, uh, and just kind of working from there. Uh. What we're moving towards apparently is fully robotic size surgeries. I was talking to Joe McCormick from Forward Thinking, and he was saying that, um, there was there's something called the Raven four, I believe. Uh. And basically you just say, this is going to be a gall bladder surgery on a six ft six male age, you know whatever, and here's his here's the cat scan of his abdomen um. So go removes gallbladder and you press enter, and thing goes in there and like removes the guy's gallbladder and sews him up. Yeah, that's fully robotic, like fully autonomous robotic surgery. Press the button and it does it. You're not actually controlling a machine that does it exactly the machines doing it at your behest, but you're not controlling it. Yeah. Um, and we're right on the cusp of that, and apparently it's already happening. Uh yeah, but there are some issues. Um. I looked into it and found that a lot of injury reporting and robotic surgery is um not being reported. It's it's substandard. And uh, this woman, Sheina Wilson, had robotic surgery for a hysterectomy in two thousand thirteen and apparently this uh intuitive surgical system had there had been a bunch of injuries that she didn't know about, and she had her wrectum burned badly and said, if I would have known that this system had these issues, would not have elected to take part in it. So there's a lot of under reporting. UM. The f d A, UM, they have no authority to force a doctor to do this, and apparently there's every reason in every link in the chain not to report these things, you know, and the f d A not enforcing this kind of thing, not enforcing reporting is ridiculous. Yeah, you know. The thing is that things like that happen, and there's under reporting um with human surg surgeons as well. Sure, not just robotic, it's like overall apparently surgical injury and accident reporting is not compulsory. Yeah, and here's here's a few points though. Counterpoints I guess is one, it's not always the robotic component of the surgery that was the cause to a lot of times they say they don't know about this until like a lawsuit is filed, so it could be weeks or months later with the physician doesn't know about it, the f d A might not get report on it, and like six months later you follow lawsuit and that's how it comes to light. UM. But the FDA is definitely concerned and are supposedly working to improve this. That's very concerned. They're very concerned. H And another problem too in that same article, a lot of these robotic surgical systems, you still have to have the correct amount of training and UH. The feeling of some experts is that UM or at least this one guy, Enrico Benedetti, he's a head of surgery at the University of Illinois, Chicago, says a lot of it just comes back to training these some of these doctors aren't getting adequately trained in these machines enough to perform the surgery. Like what happens when I do this? Oh, that happens. That's not good. I've got another alarming stat for you to hold on. Hold on, hold on. Before that, let's do a message break rel okay, tell me you're alarming stat alright. JOHNS. Hopkinsider study that found as many as forty thou patients die in intensive care each year in the US due to misdiagnosis MAN and UM. Another study found that system related factors like UH, lack of teamworking, communication, or just poor processes were involved. In six of diagnostic error and cognitive factors in with premature closure is the most common, which is basically just sticking to that admitsial diagnosis and not being open minded to other like second opinions. Yeah, so there's this thing called anchoring bias. That UM was in that New York Times article. Dr dollar Wall the guy who created this program that's now around to support diagnostics where a physician will say, I think it's this, but let me put in the symptoms and ask Isabelle um which is the name of the program, and it's named after the guy who created the Program's daughter, oh man that yeah, when she was three, took her to the hospital and the doctors said, well, she has chicken pox. And she did indeed have chicken pox, but that's all they looked at. They completely missed a pretty nasty case of necrotizing fasciitus, which we've talked about before, flush eating bacteria, and um, she almost died from it. It was it was disfigured from it as a result, so that her father, who is a money manager, said I'm going to take whatever computer programming skills I haven't put it towards this program. Isabelle which is meant to say, yes, you're right with this diagnosis, I agree with you, or have you considered these other diagnoses? And he said, like, had Isabel been around and his daughter's doctors consulted it, they would not have missed the necrotizing fasciitus. Well it makes sense, um, as an assist. You know, Um, there's this company called life Calm that said in clinical trials that if you use a medical diagnostic program as an assist, uh, those engines were accurate without using exams or imaging or labs even really just symptom. Yeah, that's crazy, that's really really really good. Yeah, like that's a that's an A, that's a low A. It's still in a. But as an assistant, I think it's you know, it's kind of a no brainer, don't you think. Oh yeah, I think so. I don't know why. I all I can think of is possibly worrying about feeding the beasts that will take your job, or just having too much of a case load to take the time to double check your work on a computer would be the only reasons why doctors aren't using that. Well, the smartphone is becoming a potential self diagnoser. There's all these cool things on the horizon that you can use your your phone for. There's one called a live Core, which you can take your own ECG test and potentially, for the cost of getting one e c G in the hospital, you could send a year's worth of daily ECGs you took yourself to your doctor, and then you carry all that info and all of your other medical info from all of your apps that will eventually be integrated into one or two apps that will probably become preloaded on your iPhone in the next couple of years, and you've got your medical history right there. Yeah, I mean, you know. Most of these require like a little clip on like um, something called cell scope that's like you clip it onto your little camera lens essentially, and it's like what are the little magnifiers with the lights that doctors used to look in your ears and eyes? Uh yeah, it looks like one of those clipped onto your your iPhone and it produces, uh, you can do imaging for skin moles and rashes and ear infections. They have one called NTRA that you could potentially give your own eyes uh, get your own like glasses prescription done, and then you order the information to some website and they say, and then this one called adamant uh that smells your breath, that smells gases in your breath and it could detect like lung cancer even yeah, apparently you have real metabolic changes to the smell of your breath when you have different types of cancer, not just long um. Like bees can detect breast cancer. Um. If you breathe into like this uh special glass fear with bees around it, they can be trained to detect lung cancer and they come back with the correct results a lot of the time. So a lot of these are on the horizon. They're not like in heavy rotation yet, no, but it's pretty neat. All of them reveal this idea that no one cares about your particular health and well being more than you unless you're one of those dudes who doesn't really care. Then your your wife does, you know, and we probably cares more about me than me, right, But there's there. The point is the doctor, the insurance company, the the hospital, while they're all in the field because they do care about your health, of course, they can't possibly care about it more than you or your loved one does. So the idea of giving you the ability to keep all of that information yourself and easily hand it over to them or potentially down the road, a computer version of them. I can't think of any any better revolution in medicine right now than that, agreed. I think it's pretty exciting. Yeah. I think we're going to live into the triple digits, buddy. Yeah. And I think there will always be a need for doctors and nurses. I don't think anyone will be wholly replaced but a little robot assist. Yeah. Yeah. Let me make one more point, all right, there's so you've heard of genomics. Yes, there's also this thing called proteonomics, which is basically your protein version of your your genome, your genome, and it's all of the proteins in your body that you have, that your manufacturing, that you're losing, and all the changes and fluctuations in them. And the idea is that you can get a full work up of your proteinome and your gino them and eventually you can add that to your medical history as well. What your e k G reading has been over the past year, um, any way you may have gained or lost or anything like that, what your breath smells like metabolically speaking, and not only have your current state of health, but personalized your version of that, personalized down to your genes and proteins in your body, so a treatment could be specifically tailored to you. Wow, that's gonna be really tough for a human physician to do that on their own. The top of that, yeah, be the the amount of data available already is overwhelming human doctors. When you add this other kind of stuff on it, it's just pulling away from them more and more. Yeah. And medical record keeping is uh. I know there's been issues with that and digitizing that and keeping up with medical records. And if you could be yourself advocate and keep up with your own medical records, it might be kind of nice. So I feel like we have heard the question. Yes, doctor, I don't know. I think in in the future, I will always have humans to interact between us. I think because we're always gonna want somebody to yell at or be like, what is this robot doing? Or can you help me this robot's give me some ipocac and won't let go on my arm or burn my wrectum. Yes, we're always going to need humans. It's just I don't know, well, we need physicians, and if we do, will they be super specialized like just the Supreme Court of Physicians. Who knows. It's pretty exciting, but we will see this change one way or another in the next fifteen years under my prediction. It's happening. Okay, good and Chuck. Yeah really, if you wanna learn more about computers possibly replacing doctors, you can type those words into the search bar how stuff works dot com. And since I said search bar, that means it's time for a message break. Okay, So so what do we have listener mail time? Yeah, I have one called I'm gonna call it fight Club. Okay, Hey, guys, just finished the podcast on deep refrigerating. I think I'll keep my Energy Star certified fridge. Thanks very much. But Josh did mentioned something about eating weeds and asked a somewhat rhetorical question, what are weeds anyway? Just plants we say are bad? Reminded me of some today's common uh some that some of today's common noxious weeds. How they got their reputation. Not so long ago, lawns were perfect blends of Bermuda rye and Kentucky bluegrass. They also included many types of clover, dandelion and other quote weeds. In fact, many seed mixtures specifically included white clover because it makes an excellent cover in soils where more common grasses won't grow In steps the Scott Fertilizer Company post World War two America housing tracks were popping up all over the US and new suburbia, and Scott was in urging returning gis to take pride in their new lawns and to buy their products to do so. And we're extremely high waisted pants, right. They produced fertilizers, weed killers, and other long care products, some of which had a curious side effect, killing many leafy greens that came up to the point that we're not considered weeds at the time, including white clover. Instead of reformulating, what they did was what any red blooded American corporation would do. They redefined what was a weed. White clover made that list as the dandelions, when in fact both are still in use today in cooking and medicines. Would you call that an oxious weed? No? So thanks for that, guys, and thanks for all the knowledge I've learned and have a great and that it's from Robert Paulson. Oh yeah, Robert Paulson. He's a he's a sharp dude. That's why I called the Pike Club. Remember that. Oh yeah, I think I made a joke to him about that once on Twitter and he never responded. Yeah, he's he writes in a lot now he's every time I see his name, I think and his name is Robert Paulson. Yeah, thanks a lot, Robert Paulson. We appreciate you. If you're ever shot in the head and the commission of a robbery, we will dispose of your body. Um. If you want to get in touch with me and Chuck and you have a name that you would like us to poke fun at, bring it on. You can tweet to us at s y s K podcast. You can post your name on Facebook dot com slash Stuff you Should Know. You can send us an email to Stuff Podcast at Discovery dot com. You can check us out on YouTube search Josh and Chuck. It will bring up our YouTube channel and you will kick your heels with glee. And then, of course go visit our website. Make it your homepage. It's the coolest place on the web. It's Stuff you Should Know dot com For more on this and thousands of other topics, is it how stuff works? Dot com Jack Heards has quickly become the online shopping destination for guys. Here's why everything on site is up to eighty percent off. As a listener of stuff you should know, you can skip the membership waitlist and get instant access that sign up dot jack threads, dot com slash no Stuff

Welcome to you stuff you should know from house Stuff Works dot com. Hey, and welcome to the podcast. I'm Josh Clark. There's Charles W. Chuck Bryant. Our guest producer Noel is here. Yeah, Jerry needs a buffer day from her Christmas break. I can't say that again. No, she's at home on her buffer day. And the freezing cold because we record these somewhat in advance, we are in the midst of the polar vortex and um, yeah, everyone's just talking about how cold is We're back. It is our first recording after the holidays. It's literally freezing cold up. So welcome back, buddy, Thanks, Welcome back to you too. Even though this will be what like late January, it will be a balmy sixteen Atlanta. I think the end of the end of January is when this one comes out. All right, Well, happy New Year, and happy New Year to YouTube, and happy holidays to you. Thanks. Um Chuck, Yes, sir, you're feeling good. You're loose, You're ready. I'm loose. So you see this. You've seen this before. Yeah, you're fit. My fit bit is that buzz marketing? Not really, It's just a really good example. Um I've felt like Fitbit, I'm not like necessarily loyal to it or anything like that. They don't pay me money to mention the podcast. Sometimes it's be like, stop staring at me fit Bit. Um. But no, I like it. I'm happy with it. Um. I I pointed out though, because it's part of this to me, and I don't think it's over confirmation bias. It seems like there really is a growing desire among just average ordinary people to be able to track there their health, their well being, their activity, um, and to do it easily. Yeah, we have tools now that make it, like that thing super convenient. Yeah, it's and Fitbit's not the only one. There's like Nike fuel Band. There's Jawbone is another really good one. There's others like um that track uh, your galvanic response, so they're able to put that together with respiration and heartbeat and come up with a pretty good assessment of how many calories you're burning at any given time, which is like kind of a holy grail with this kind of thing right now. Um, there's others that check your sleep. There's apps out there that let you um check your mood. Um. There's sites like Quantified Self which are basically like people trying to push wearable technology like this further into the future. There's entire websites like share care dot com that are dedicated to health information and health um uh support self advocacy. Yeah, and there's this. It seems to me, this desire to kind of say, hey, this is my health, this is my body. I want to know more about it, you know, like I don't want to necessarily cut out doctors, but I I I want to decide if I should go to the doctor, if it's time or not, and I want to use data to do that. Yeah. I imagine U. I frustrate a lot of doctors because I'm one of those obnoxious people that goes in and it's like, well, here's what I think I have based on my research. There's nothing wrong with that. Yeah, that is what you're an informed patient. That's true, exactly what you're supposed to do. And if you're getting on your doctor's nerves, then go see another doctor. Yeah, I agree. Actually in search of a new GP right now for those because and others you got on his nerves other reasons too. Really cold cold hands like poor bedside man are never seen the doctor, like here's my intern from Emory. Yeah, which great. You know. I love them getting experienced, but I would like them both to be in there, not just like smell you later and the doctor leaves. Well that's another thing too. It's kind of like, um, doctor, okay, let's let's just lay it on on the table here. Yeah, what what you've just mentioned and what I was talking about. If you put it all together, the medical field physicians in particular, are currently in a what's the beginning of what's possibly a really pickle of a state for them. I think a transition period, yes, but they may be transitioned right out of existence in large parts. Yes, some may for sure, depending on who you talk to. There's like this whole question now, like what is the future of medicine and more specifically, in the case of this episode that we're talking about, do human physicians factor largely into that future? And the answer is I don't know, yeah, depending on who you ask, Like I said, um, we there's this one guy, Dr Kent Bottles, who um he feels that GPS might go the way of the DODO and be replaced by diagnostic computers, maybe with avatars. Then there's other people like Farhad Manjou's a technical writer, his wife as a pathologist. He thinks, no, no no, no, the gps are the ones that are going to be in business. The specialists are gonna be out of business because computers are really good at specializing on one single thing, not maybe so good at a general practitioner thing. So there's lots of opinions out there on how much they'll be replaced and who might be replaced. Right then, As Reclined wrote a column who basically he basically said like no, like we we will still need humans, but we mainly need humans to communicate to the other humans and facilitate the the interaction between the robots and the humans. And we already have this. They're called nurses or nurse practitioners. Yea. But he kind of as Reclined is the one that thought that a computer avatar might have a better bedside manner than a doctor. Well, let's give that one example. There's this, there was there's an example I kept finding while we were doing research for the sentence. Actually in the article on how stuff works. Um, it's uh. There was a kiosk, a medical kiosk, during a panel called man Made Minds colon living with thinking machines. When there's a colon in there, you know it's serious stuff. Um. And it was at the World Science Festival in two thousand eleven, and basically this, this computerized avatar UM interacted with a woman whose baby had diarrhea, and the woman said, hey, Avatar, my baby has diarrhea. What are you gonna do about it? And the avatar said, well, tell me all the symptoms and all this stuff, and avatar decided that the baby's diarrhea, while present, wasn't severe enough to warrant immediate medical attention, so it went ahead and made an appointment with a human doctor for later on that week. And the mother said that she preferred the treatment by the avatar to the real life nurses at the hospitals where she lived in New York. Yeah. Uh, so it is possible to create computers with better bedside manner than say, your g P. Well, it's at the very least it will be consistent. And that's one of the things that I'm not poopooing. Doctors or nurses are many, many, many, many great ones, but I've also had some pretty bad experiences, as in emergency rooms and with doctors and nurses with a computer. At least it's a consistent you know, their program to display empathy no matter what. You know, they're not too busy and they're not you know, having a bad day, so they they don't you know, they don't have any prejudices against you personally or anything like that. They're a computer. They don't hate diarrhea. But humans, humans respond to even programmed empathy, even synthetic empathy from a computer. I could see that a little bit. Like I've dove into the gaming world enough to know that, you know, the realism of a of a avatar can be convincing, and it's not like you think, oh, it's a real person, but it helps to put a human face on it, you know, exactly literally. Um, they saw a reference to a study that found um, people who are being treated for anxiety disorders tended to share more about their experiences and themselves with an avatar them with a human psychiatrists. Oh that's interesting because they're like not embarrassed to tell a real person. Yeah, that makes sense. I might open up more to to a computer. Right, So so we've got that part, like the bedside manner, it is possible that we can create machines now and are creating machines now that have at least equal, if not better bedside manner than some physicians. Yeah, okay, so bedside manner one of the big things that doctors bring to the table. Check computers have that. Yeah, it's it's different now than it was in the old days. I feel like just the whole quality of personal care is gone down. It's not necessarily the doctor's falts. There's a lot of reasons to place the blame, but it's not like when you were a kid and you feel like you had your family doctor who knew you, maybe even gave birthth you're my son exactly. Um, it just invested like you gotta stick with the same doctor if you want that kind of care, I think, right, And is another benefit besides bedside banner um that comes with that that kind of care, that kind of personal care is an awareness of your medical history. Not just that but oh well, your dad died of congenital heart disorders like that, so you may be at higher risk of it. To just that kind of awareness has been typically lost too. Even though we have medical histories and they're in our charts that they're in our files UM, and intimate knowledge of a patients UM medical history is pretty much lost in today's modern practice of medicine. UM. That's another thing that that computers could conceivably top doctors on UM, which basically falls under the umbrella of diagnosis or diagnostics. Yeah. I mean there's two two sides to this. There's diagnoses and treatment and some UH programs. A little bit of the history this UM goes back to the nineteen seventy is at the University of Pittsburgh. They develop software to diagnose problems. UM. MASS General since the eighties has been working on their d X plan, which provides ranked lists of diagnoses, whereas the what's the computer the Watson Watson who who won a Jeopardy Yeah, that's more based UM. It looks like on treatment options than diagnosis at this point. So well, yeah, but they said it's not They haven't. I don't think they want to leave it alone with diagnosis yet. No, and to do its thing there there's already something out there for diagnosis that's meant to support physicians. From what I understand with Watson, if there is a doctor of the future, it's Watson. Yeah. UM, he has a lot of advantages over not just um human doctors, but other artificial intelligence healthcare machines. I guess you could clumsily call he has a knack for natural language. So let's say there's like a structured formula or formulaic type of language that the medical field is supposed to use, right, yes, okay, um, health records don't always necessarily contain that language. They might contain natural language, which is really confusing for computers to take in an absorb. Yeah. You know, humans can pick up on meanings of things that robots and and software cannot, like inferences, and we might be using sarcasm, although there's probably not going to be any sarcasm in your medical records. Yeah, but like figurative language and stuff like that. But computers a language is a big part of the problem. Or more to the point, with the diagnosis, patient says he feels like he has a hive of bees in his stomach. Like that might mean something that you or me, but to a computer it's like followed the two bees or something. Right, Watson has the advantage of saying, Okay, well there's a sensation of bees in the stomach, there's not actually bees in the stomach. So let's figure this out then, Watson or anything that that he eventually becomes. UM, Well, we'll be able to go through medical records, current medical research, UM, the patient's medical history, uh, diagnostic tests that were done, blood work, instrument tests, and put it all together and then spit out a list of diagnoses with different confidence levels. So the one at the top is the one that Watson says is he is ninety eight point percent sure is what's wrong with this patient? And UM as a diagnostician, that's pretty impressive. And that's using all the available data that's that's available also to human physicians, but they simply don't have the time to make it all in. Yeah. I think some research said that eighty percent of doctors spend less than five hours a week reading medical journals a month a month. Yeah, so that's these things can read thousands in seconds. So it's it's sort of a matter of of efficiency really, and like if doctors don't have time to read all this stuff, I know, we we looked into this one. Uh sort of a savant diagnoser is that a word? Diagnostician? Uh? Doctor uh Dolly Wall in San Francisco. He's sort of legendary for diagnosing things, to the point where he does it on stage as almost like a parlor trick would do. They give him forty five minutes and and a bunch of symptoms basically like really confusing because they're trying to stump him, and generally he comes out on top. But he even uses a program, a diagnostic program called Isabelle. Right, that's the one I said every here that's already here. So doctors are using these to help themselves out. But he says that he's never had Isabelle offer a diagnosis that he has missed. Right, But he's like the dude that yeah, And he also admits that he's like like I'm a freak of nature. Go ahead, quiz me exactly. He also reads like case histories, like for fun, that kind of stuff. He's not, he's not a normal physician. He's a complete and total outlier. Um, if he were. If every physician were like this guy, then they're there probably wouldn't be this conversation going on right now. But most physicians aren't. And it's not just with current medical research that they're just not aware of because they haven't had time to pick up the lancet the last few months, but it's also their training to Like, if a doctor is in practice for twenty years, the brain, and the human brain tends to create habits because it likes to expend as little energy as possible. It's it's trying to be as ficient as possible. And I think the same thing happens with medical practice. You're trained, you understand, you come out of medical school with a lot of book learning, and then you put it to practice and you kind of find your niche and along the way you forget a lot of the stuff that you haven't done in twenty years or haven't learned about in twenty years. So it's not just current stuff, it's old stuff too. And if you feed the physician's desk reference into Watson or one of his his compatriots, like all of that knowledge can be quickly index and research to try to spit out a more accurate diagnosis. Yeah, I think that's a great idea. It's like a partnering up with computers. It is sarily replacing, but what they're doing with Watson is is very much moving towards replacing doctors in that sense. Well, here's a scary stat um one in five diagnoses in the United States are incorrect or incomplete one in five and a lot of times. It's not that the doctor's a jerk or not any good, but like you said, they just maybe haven't seen these cases that were written about in some obscure medical journal that the computer has scanned an index. Ya and Dolly Wall Dr Dolly Wall himself at Freak Diagnostication Dollywood, Yeah, pretty close, which is a wonderful place. By the way, um Dr Dolly wall Uh himself says a lot even with me, A lot of it is intuition, and intuition can be wrong. That's a criticism though, of computers as doctors. They lack intuition. Like there's kind of even a larger even larger than this computer's replacing doctor's conversation going on. It's kind of a conversation or a debate over whether intuition or data. Yeah, Trump's one or the other. Which one is the right way to go? Yeah? This one step too, it says according to an expert, I'm not sure what that means. That sounds sinky, but they said, only of the knowledge of physicians use to diagnose is evidence based, so that means intuition, which which also jibs in dovetails with that one in five being wrong or one in five being right. I'd like the idea of intuition to a certain degree, for sure, but there's also got to be like data backing it up. Sure, you know so in your perfect world. Then it sounds like we still have physicians, but they go back and double check themselves using a program. Yeah, but I could also be down with um simple what is it? What do they call it in here? Um? Something based diseases, rules based chronic diseases. Yeah, like minor things that are pretty easy to diagnose, so they're not even necessarily minor. We just understand them so fully that we say type two diabetes is going to behave and present itself like this. Yeah, but I wouldn't mind going like it seems like once a year I get, like an upper respiratory infection. It's been three or four years in a row, and I know what the treatment is, I know how it feels. It would be great to go and to a machine and have them take some stats and blow into it and hear my wheezing and give me a a steroid shot and a Z pack and a breathing treatment and send me on my way. So it's always what clears it up. Would you care if it was a robot that gave you that shot? Not at all, um, but I definitely would want more personal care if it was something. What if it was a robot with a nice avatar, sexy avatar or just a friendly one. Yeah, that was a little, a little, a little it would touch your forearm here there. Yeah, well that might be a little creepy. Yeah, it's like it was an old timey doctor who like gave you some epocac if you had diarrhea, just send you on your way, drink a coke. But it wouldn't send you on your way to give you ip acac and then it wouldn't let go of your forearm. Yeah. Well, surgical robots, that's a that's a thing. I mean, we're getting around, but they've been performing they've been performing robotic surgery since the early eighties. Um doctor assisted until two thousand ten, where they were in Montreal. They performed the first fully robotic surgeries when they removed a prostate with the fully robotic UH surgeon and fully robotic anentusiologist Dr mc sleepy Dr mc sleepy. Yeah, and then that's the real name the robot surgeon was da Vinci, which is like the basically gold standard for robotic surgical or surgical robots. Yeah, they had in two thousand, thirteen fifty thousand robotic surgeries performed in the US. So it's it's big and um. But the da Vinci is a doctor basically sitting in a little uh it looks like an arcade game and using um robotic arms to mimic his or her movements on more microscopic levels. Right, So the robot has more precise movements and can make smaller movements, um than the doctor. It's tell it's and what's the opposite of telescoping, like going downward in scale? Whatever that is. It's taking the movements of the doctor and reducing them in scale. Let's call it reverse telescoping, reverse telescoping those movements, um, which is a pretty awesome achievement in and of itself. That doctors being fed three d um graphics of what the robot is seeing, uh, and just kind of working from there. Uh. What we're moving towards apparently is fully robotic size surgeries. I was talking to Joe McCormick from Forward Thinking, and he was saying that, um, there was there's something called the Raven four, I believe. Uh. And basically you just say, this is going to be a gall bladder surgery on a six ft six male age, you know whatever, and here's his here's the cat scan of his abdomen um. So go removes gallbladder and you press enter, and thing goes in there and like removes the guy's gallbladder and sews him up. Yeah, that's fully robotic, like fully autonomous robotic surgery. Press the button and it does it. You're not actually controlling a machine that does it exactly the machines doing it at your behest, but you're not controlling it. Yeah. Um, and we're right on the cusp of that, and apparently it's already happening. Uh yeah, but there are some issues. Um. I looked into it and found that a lot of injury reporting and robotic surgery is um not being reported. It's it's substandard. And uh, this woman, Sheina Wilson, had robotic surgery for a hysterectomy in two thousand thirteen and apparently this uh intuitive surgical system had there had been a bunch of injuries that she didn't know about, and she had her wrectum burned badly and said, if I would have known that this system had these issues, would not have elected to take part in it. So there's a lot of under reporting. UM. The f d A, UM, they have no authority to force a doctor to do this, and apparently there's every reason in every link in the chain not to report these things, you know, and the f d A not enforcing this kind of thing, not enforcing reporting is ridiculous. Yeah, you know. The thing is that things like that happen, and there's under reporting um with human surg surgeons as well. Sure, not just robotic, it's like overall apparently surgical injury and accident reporting is not compulsory. Yeah, and here's here's a few points though. Counterpoints I guess is one, it's not always the robotic component of the surgery that was the cause to a lot of times they say they don't know about this until like a lawsuit is filed, so it could be weeks or months later with the physician doesn't know about it, the f d A might not get report on it, and like six months later you follow lawsuit and that's how it comes to light. UM. But the FDA is definitely concerned and are supposedly working to improve this. That's very concerned. They're very concerned. H And another problem too in that same article, a lot of these robotic surgical systems, you still have to have the correct amount of training and UH. The feeling of some experts is that UM or at least this one guy, Enrico Benedetti, he's a head of surgery at the University of Illinois, Chicago, says a lot of it just comes back to training these some of these doctors aren't getting adequately trained in these machines enough to perform the surgery. Like what happens when I do this? Oh, that happens. That's not good. I've got another alarming stat for you to hold on. Hold on, hold on. Before that, let's do a message break rel okay, tell me you're alarming stat alright. JOHNS. Hopkinsider study that found as many as forty thou patients die in intensive care each year in the US due to misdiagnosis MAN and UM. Another study found that system related factors like UH, lack of teamworking, communication, or just poor processes were involved. In six of diagnostic error and cognitive factors in with premature closure is the most common, which is basically just sticking to that admitsial diagnosis and not being open minded to other like second opinions. Yeah, so there's this thing called anchoring bias. That UM was in that New York Times article. Dr dollar Wall the guy who created this program that's now around to support diagnostics where a physician will say, I think it's this, but let me put in the symptoms and ask Isabelle um which is the name of the program, and it's named after the guy who created the Program's daughter, oh man that yeah, when she was three, took her to the hospital and the doctors said, well, she has chicken pox. And she did indeed have chicken pox, but that's all they looked at. They completely missed a pretty nasty case of necrotizing fasciitus, which we've talked about before, flush eating bacteria, and um, she almost died from it. It was it was disfigured from it as a result, so that her father, who is a money manager, said I'm going to take whatever computer programming skills I haven't put it towards this program. Isabelle which is meant to say, yes, you're right with this diagnosis, I agree with you, or have you considered these other diagnoses? And he said, like, had Isabel been around and his daughter's doctors consulted it, they would not have missed the necrotizing fasciitus. Well it makes sense, um, as an assist. You know, Um, there's this company called life Calm that said in clinical trials that if you use a medical diagnostic program as an assist, uh, those engines were accurate without using exams or imaging or labs even really just symptom. Yeah, that's crazy, that's really really really good. Yeah, like that's a that's an A, that's a low A. It's still in a. But as an assistant, I think it's you know, it's kind of a no brainer, don't you think. Oh yeah, I think so. I don't know why. I all I can think of is possibly worrying about feeding the beasts that will take your job, or just having too much of a case load to take the time to double check your work on a computer would be the only reasons why doctors aren't using that. Well, the smartphone is becoming a potential self diagnoser. There's all these cool things on the horizon that you can use your your phone for. There's one called a live Core, which you can take your own ECG test and potentially, for the cost of getting one e c G in the hospital, you could send a year's worth of daily ECGs you took yourself to your doctor, and then you carry all that info and all of your other medical info from all of your apps that will eventually be integrated into one or two apps that will probably become preloaded on your iPhone in the next couple of years, and you've got your medical history right there. Yeah, I mean, you know. Most of these require like a little clip on like um, something called cell scope that's like you clip it onto your little camera lens essentially, and it's like what are the little magnifiers with the lights that doctors used to look in your ears and eyes? Uh yeah, it looks like one of those clipped onto your your iPhone and it produces, uh, you can do imaging for skin moles and rashes and ear infections. They have one called NTRA that you could potentially give your own eyes uh, get your own like glasses prescription done, and then you order the information to some website and they say, and then this one called adamant uh that smells your breath, that smells gases in your breath and it could detect like lung cancer even yeah, apparently you have real metabolic changes to the smell of your breath when you have different types of cancer, not just long um. Like bees can detect breast cancer. Um. If you breathe into like this uh special glass fear with bees around it, they can be trained to detect lung cancer and they come back with the correct results a lot of the time. So a lot of these are on the horizon. They're not like in heavy rotation yet, no, but it's pretty neat. All of them reveal this idea that no one cares about your particular health and well being more than you unless you're one of those dudes who doesn't really care. Then your your wife does, you know, and we probably cares more about me than me, right, But there's there. The point is the doctor, the insurance company, the the hospital, while they're all in the field because they do care about your health, of course, they can't possibly care about it more than you or your loved one does. So the idea of giving you the ability to keep all of that information yourself and easily hand it over to them or potentially down the road, a computer version of them. I can't think of any any better revolution in medicine right now than that, agreed. I think it's pretty exciting. Yeah. I think we're going to live into the triple digits, buddy. Yeah. And I think there will always be a need for doctors and nurses. I don't think anyone will be wholly replaced but a little robot assist. Yeah. Yeah. Let me make one more point, all right, there's so you've heard of genomics. Yes, there's also this thing called proteonomics, which is basically your protein version of your your genome, your genome, and it's all of the proteins in your body that you have, that your manufacturing, that you're losing, and all the changes and fluctuations in them. And the idea is that you can get a full work up of your proteinome and your gino them and eventually you can add that to your medical history as well. What your e k G reading has been over the past year, um, any way you may have gained or lost or anything like that, what your breath smells like metabolically speaking, and not only have your current state of health, but personalized your version of that, personalized down to your genes and proteins in your body, so a treatment could be specifically tailored to you. Wow, that's gonna be really tough for a human physician to do that on their own. The top of that, yeah, be the the amount of data available already is overwhelming human doctors. When you add this other kind of stuff on it, it's just pulling away from them more and more. Yeah. And medical record keeping is uh. I know there's been issues with that and digitizing that and keeping up with medical records. And if you could be yourself advocate and keep up with your own medical records, it might be kind of nice. So I feel like we have heard the question. Yes, doctor, I don't know. I think in in the future, I will always have humans to interact between us. I think because we're always gonna want somebody to yell at or be like, what is this robot doing? Or can you help me this robot's give me some ipocac and won't let go on my arm or burn my wrectum. Yes, we're always going to need humans. It's just I don't know, well, we need physicians, and if we do, will they be super specialized like just the Supreme Court of Physicians. Who knows. It's pretty exciting, but we will see this change one way or another in the next fifteen years under my prediction. It's happening. Okay, good and Chuck. Yeah really, if you wanna learn more about computers possibly replacing doctors, you can type those words into the search bar how stuff works dot com. And since I said search bar, that means it's time for a message break. Okay, So so what do we have listener mail time? Yeah, I have one called I'm gonna call it fight Club. Okay, Hey, guys, just finished the podcast on deep refrigerating. I think I'll keep my Energy Star certified fridge. Thanks very much. But Josh did mentioned something about eating weeds and asked a somewhat rhetorical question, what are weeds anyway? Just plants we say are bad? Reminded me of some today's common uh some that some of today's common noxious weeds. How they got their reputation. Not so long ago, lawns were perfect blends of Bermuda rye and Kentucky bluegrass. They also included many types of clover, dandelion and other quote weeds. In fact, many seed mixtures specifically included white clover because it makes an excellent cover in soils where more common grasses won't grow In steps the Scott Fertilizer Company post World War two America housing tracks were popping up all over the US and new suburbia, and Scott was in urging returning gis to take pride in their new lawns and to buy their products to do so. And we're extremely high waisted pants, right. They produced fertilizers, weed killers, and other long care products, some of which had a curious side effect, killing many leafy greens that came up to the point that we're not considered weeds at the time, including white clover. Instead of reformulating, what they did was what any red blooded American corporation would do. They redefined what was a weed. White clover made that list as the dandelions, when in fact both are still in use today in cooking and medicines. Would you call that an oxious weed? No? So thanks for that, guys, and thanks for all the knowledge I've learned and have a great and that it's from Robert Paulson. Oh yeah, Robert Paulson. He's a he's a sharp dude. That's why I called the Pike Club. Remember that. Oh yeah, I think I made a joke to him about that once on Twitter and he never responded. Yeah, he's he writes in a lot now he's every time I see his name, I think and his name is Robert Paulson. Yeah, thanks a lot, Robert Paulson. We appreciate you. If you're ever shot in the head and the commission of a robbery, we will dispose of your body. Um. If you want to get in touch with me and Chuck and you have a name that you would like us to poke fun at, bring it on. You can tweet to us at s y s K podcast. You can post your name on Facebook dot com slash Stuff you Should Know. You can send us an email to Stuff Podcast at Discovery dot com. You can check us out on YouTube search Josh and Chuck. It will bring up our YouTube channel and you will kick your heels with glee. And then, of course go visit our website. Make it your homepage. It's the coolest place on the web. It's Stuff you Should Know dot com For more on this and thousands of other topics, is it how stuff works? Dot com Jack Heards has quickly become the online shopping destination for guys. Here's why everything on site is up to eighty percent off. As a listener of stuff you should know, you can skip the membership waitlist and get instant access that sign up dot jack threads, dot com slash no Stuff