As a future physician, the concept of AI in healthcare is super intriguing to me, albeit slightly intimidating. I love the way Ashleigh approaches the topic, remaining neutral and addressing both the positive and negative potentials of AI in healthcare. She says in her talk that 80% of what family physicians do now will be replaced by AI, and while that number is quite shocking, I think it is also important to realize that we are already utilizing AI in things like diagnostic algorithms, ophthalmology, Alzheimer disease, and numerous other areas. AI is rapidly becoming a standard of care in some areas, and the technology is advancing enough to potentially surpass that of what humans are intellectually capable of, but like Ashleigh says, the direction this technology goes depends almost entirely on the consumers, being the healthcare providers and the patients. One of the most important aspects of quality medical care is that of the doctor-patient relationship, and we’ve already seen a huge decline in this particular sector, with an all time high of patient dissatisfaction with their physicians on the basis of not being heard and not connecting. With this in mind, I think it would be a feat to gain the trust of the public in relinquishing their care to a robot. That being said, Ashleigh also talks about the potential for programming AI systems with the ethical values of humans, and whether this is really possible, I don’t know, but if it is, it seems like there would be potential for human physicians to become outsourced. We already know that AI can surpass the level of human intelligence, but if we can combine that with the ability for it to maintain ethical standards, the quality of healthcare could be exponentially better, and this poses an extremely challenging debate for medical ethics. The principle of beneficence and non-maleficence means to do the most good and to do no harm, so if we have the capability to exceed the quality of care we are currently able to provide, are we going against this principle by not implementing it? It’s a very multifaceted debate that must consider every single aspect of ethics, for example, this technology is undoubtedly extremely expensive, limiting its use to only those who can afford it and furthering the ever-prevalent socio-economic disparity in healthcare, which violates the justice pillar of ethics, which calls for fair and equitable distribution of all health resources. There are a slew of hurdles that would have to be overcome in order to implement a standard of AI in healthcare, but I believe that it absolutely should by healthcare professionals as a tool and resource to guide their care and to minimize errors, ultimately in the benefit of the health of our society.

Firstly, I just want to say that this talk was very interesting. I like how Ashleigh introduced Sophia and the idea that most of the our future healthcare needs may be handled by AI like Sophia. I also think Ashleigh did a great job of playing devil’s advocate and maintaining an unbiased stance. Ashleigh mentioned a statistic that I think really puts things into perspective. She said “80% of what our family physicians do will be replaced by AI”. This shows just how quickly AI is advancing and moving into the healthcare sector. AI undoubtedly has a great deal of potential, and Ashleigh touched on this with several examples. There is no denying the benefits of bionic eyes and prosthetic limbs that allow their users to hone fine motor skills. Or a spinal cord injury quadriplegic that can control an exoskeleton by using only their brain, allowing them to move a limb that they otherwise wouldn’t be able to. These are examples of amazing medical advancements using AI that should be celebrated. But as Ashleigh mentioned, AI is advancing so fast that we are in a gray space where we don’t understand helpful vs harmful. So, what’s the catch? As Ashleigh mentioned, the AI technology in the previously mentioned examples isn’t cheap. Creating and using these technologies increases economic division as only certain patients or countries that can afford them will reap their benefits. This is an extremely challenging situation for medical ethics. Using the ethical principal of beneficence, which means to do good, I believe the stance would be to allow those who can afford the AI devices to purchase them. You are doing good to those patients and altering their lives in a positive meaningful way while not directly causing harm to the patients who can’t afford them. However, I believe this violates the justice principle. This principal calls for a fair and equitable distribution of health resources. Denying people/countries access to these AI technologies based on their economic standing breaches this principle. Viewing this from an ethical utilitarianism concept, I believe we should scratch the immense amount of funds put into creating these AI technologies that would benefit one person, and instead allocate the funds to cheaper forms of therapy to treat dozens of people. An example would be for Parkinson’s. You can provide dozens possibly even hundreds of patients with pharmaceutical treatments for Parkinson’s for the same price as one of the AI technologies. This talk has really sparked my interest because I’m not sure which approach would be best or which principal would trump the others in this circumstance. I think Ashleigh also touched on two other important aspects of medical ethics and AI, safety and transparency. Ashleigh stated that the physician will still have the final say. This provides patients with a sense of safety knowing that their physician will ultimately still be heading their care and that the AI devices are just there to assist however the physician sees fit. I know for me personally a big form of fear has been in this idea that AI will completely replace healthcare providers and this statement helps to debunk that. Ashleigh also mentions that transparent algorithms are being developed so that both physician and patient can understand the technology that is being used.

This is such an interesting video. When I think about ethical problems, I forget that AI is such a vital role and has to be closely monitored. As Ashley explained in the video, which I think she did a great job to make sure she was unbiased, that AI can help so much in the healthcare world. I do think that ethical problems can be faced when it comes to equality in healthcare. AI is expensive in all aspects and as it is, there is a division of healthcare and who can afford it. It would be amazing if AI was used to give access to healthcare to everyone regardless of background, social economic status, or education of technology. Unfortunately, I think this is unrealistic in the world we live in today. There were some great examples used such as using AI for brain stimulation, limb prosthetics, and such, but only those that are already wealthy would be able to afford it. Also, to those that are not fortunate enough to have technology based education, it can be discouraging because they will not understand how such things work and will not be able to incorporate this new invention into their daily lives. Another medical ethical standpoint that can be argued, is the fact of privacy and autonomy. How can a patient determine what is being shared with the AI and where that information is stored/sent? This can lead to increased fear and mistrust in both physicians and healthcare. The patient might also feel that they would not have the autonomy to determine their care, which is against what we as future physicians want for our patients. I think that AI can be extremely useful and both help patients and physicians in the future, but I do think that there needs to be regulations and guidelines. There also needs to be more education and awareness spread about what exactly AI is and what it can do. AI is such a controversial topic because in some cases, a lot of healthcare workers do not want this technology implanted in healthcare. As students and those of us involved in the healthcare world, we have spent hours upon hours studying, giving up our time and special occasions in life, to only be replaced with technology. I understand this can be very helpful in some cases but my opinion is that AI is not always the best option. Sometimes the best medicine is human interaction and treatment.

My comment: I would like to start by saying thank you to Mrs. Kennedy for this incredibly interesting talk. I think this is about as relevant as a talk as there should be in this day of healthcare. We are already seeing some of the power of AI and what it can do. There are several applications today that are able to do the workload of a physician in a matter of seconds. Mrs. Kennedy addressed the “Hollywood version” of the singularity, where AI “takes over” humanity. Yet, what about what it means to be human. I am all for AI in healthcare, I think it will cure diseases in a matter of months in relation to what it would takes humans fifty years. However, I think that is all AI should be doing. When it comes to distributing health resources, I think that we need to keep the human in health care. The principles of autonomy, beneficence, non-maleficence, and justice are human principles that an AI could not understand to the emotional standard that humans do. It is one thing to understand a definition and an algorithm to follow these principles, but it is another thing to feel the weight of the emotion that these principles represent. In a perfect world, AI would remain in our laboratories helping humanity cure disease, find better management strategies for current disease, while respecting the human desire to treat patients. I believe that only humans can follow the four fundamental ethical principles because it is humans that saw the need to establish them. These principles are fundamental to helping the patient heal and must remain in our regimen. AI can only make healthcare better, more efficient, more effective and I think the integration should be starting sooner than later. In closing I would like to thank Mrs. Kennedy again for sharing her knowledge and life experience with us. I hope to see this discussion come to life. Thank you for reading.

Innovative speech. The future is the limit.

Very interesting and innovative presentation. The future is bright with AI, the possibilities are limitless😁😁 , I am very much excited.

Ashleigh did an amazing job addressing the effects that AI could have and is already having on our healthcare system. Physicians swear an oath that addresses beneficence, maleficence, autonomy, and justice. I consider these values to be deeply rooted on the human touch and find it difficult to comprehend how an AI system, could one day develop these values. During the talk, Ashleigh mentions that the incorporation of AI in medicine enhances the human experience without human input. She continues by saying that this takes away the agency from the patient. Agency refers to personal autonomy. And in the case of medicine, autonomy over a patient’s own health. As medical providers, we respect a patient’s wishes over their health and honor their decisions. The bionic eye, although incredibly impactful to bring vision back to patients, might actually control and limit the patient’s autonomy. This would be an example of how incorporating AI into medical treatments would violate the hippocratic oath. Another argument brought up by Ashleigh was that these technologies are not cheap, per se. These are expensive and as a result, those able to afford these forms of treatment are wealthy individuals. Marginalizing medicine, worsens the already existent economic disparity our society is in. Furthermore, creating an elite or favorable group of individuals who can afford better health, versus those who cannot. I agree with Ashleigh. This entire concept reminds me of the movie Gattaca and dismantles the idea that healthcare should be universal and affordable for the general patient. I am reluctant to fully welcome AI into medicine, but I also recognize that it can used as a tool to enhance our accuracy. However, I am not so sure how AI will be able to mimic the human essence, I consider, only humans can accomplish.

I love the continued innovation that the human race facilitates in all aspects of life especially in healthcare. From working in a clinic to working at a hospital I have seen new technology implemented in communication, data storage, and even patient care. However, with each innovation comes the same problem, workers always impede progress because change is hard and not always perceived as good. An example of this would be when the last hospital I worked at introduced the use of a new hands-free communication device and upgraded from the already “very advanced pager.” The individuals I was working with at the time had been with the hospital for 15+ years and could not wrap their head around this new technology. They fought the use of the handheld communication device for about a year until they realized how much it improved communication and decreased the number of missed exam orders. This technology was still not perfect after that initial year but continued to improve and improved even faster as individuals accepted the change and offered input on changes that could be made like Ashleigh mentions in her Ted talk. I think if a proper implementation strategy can be established, AI could make a huge difference in the healthcare system to improve efficiency in caring and curing the illnesses of our communities. The biggest issue I have with AI being included in the care of patients is the lack of humanities higher functioning dynamic of emotion and empathy. While there continues to be huge leaps in technology there is nothing quite like the human brain and its ability to sense human emotion and connect with that emotion. While the AI programs may be altered or written to account and read human emotions, will they really have the beneficence and non-maleficence to help patients? In a critical situation will the AI be able to think logically, ethically, and consider factors that are beyond statistical factoids? I recently watched another video where an individual compared two physicians, one who truly connected with her and helped her solve her chronic illness and one that was cold showing no emotion and ignoring her mental/emotional needs. This individual obviously preferred and felt more comfortable with the physician that truly connected with her. When we begin to remove the human factor from primary care settings, we will lose those vital connections that come from a physician. While AI is likely to make less mistakes than their human counterparts there are still many aspects of medicine and the needs of humans that cannot be fulfilled by AI. As a society, and even myself as a future physician, we often overlook the broader aspect of medicine, we are not simply curing a disease, but we are improving the physical, spiritual, and mental health of a real person. I think with this in mind there is certainly a place for AI in the world of healthcare if a physician is overseeing the proper care and implementation of this healing technology.

Nice video worth pondering over. Hearty thanks to the producers and to my lecturer for sharing this video link with me.

Ashleigh made a lot of great points in this presentation. I think for the most part, the applications of AI in healthcare are tremendously helpful and beneficial for the general population; especially in helping people who couldn’t have otherwise walked on their own, physically see their loved ones, perform everyday tasks on their own. I think the biggest ethical dance that comes in to play for me personally is the ethical component of justice: will our healthcare system be able to allow this kind of care to be affordable and accessible? For example, if a physician is present for the co-provider method, how will this affect the minimum co-pays and cost of care? Would that technically count as seeing two providers? The technology used for this type of AI will be extremely providential for our future patients but also costly. Which is where this dance also becomes more complex: how much does it truly cost to be able to develop and use this kind of technology in our communities? And how much will the companies, medical offices, and insurance companies charge for their profit? These are all concerns that Ashleigh is also concerned about as well. But with our current healthcare system and its costs, it’s not safe to assume that they would these goods would be effectively distributed. My other concern from an ethical standpoint is beneficence.

@musicobsessed95

Жыл бұрын

I definitely agree with the greater potential socioeconomic implications of AI's involvement in healthcare that you have point out. In terms of health insurance/healthcare billing and coding- the use of AI quickly becomes complicated. There is already great disparity within the medical field for many individuals when it comes to healthcare equity and access. My hope is that it could potentially increase access to those in need, such as in rural areas. However, the overall cost of the impressive technology could lead to even further divisions and divides amongst individuals when it comes to receiving healthcare. Extensive testing and further research on the financial ramifications would be very important and necessary to conduct.

To be fair, how much access we really have to medicine?

Dr. Kennedy’s discussion regarding ethical considerations within AI healthcare compares how beneficial these cutting-edge technologies can be while also keeping a watchful eye on the cost of our humanity and amount of control. Dr. Kennedy warns how easily AI and healthcare can become convoluted within the realm of medical ethics if not carefully handled. A primary example she provided was how some discovered technologies may only be available to those who can afford it, thereby thwarting the medical ethics principle of justice. Similarly, the use of genetic testing for patients may not be as beneficial or non-maleficent as it seems, as insurance companies can use the genetic information against patients, leaving physicians (and patients) in precarious positions. One question that seems to always surface within developing and applying new technology is the question of not if we can reach new heights in applying new technology within the field of healthcare (or within many other fields), but rather should that new technology be applied. As much as I applaud new technologies within healthcare, I am always cautious in what exactly is being sacrificed to provide for “the greater good.” Finally, regarding the concept of humanity, life-like robots may not become as easily burned out or perhaps not make as many medical errors as a human physician might. However, I don’t believe there is any technology that can replace the human touch of emotions such as empathy or sympathy or the human brain’s capacity of executive functioning.

I really appreciate Ashleigh Kennedy discussing both the helpful and frightful aspects of implementing artificial intelligence in medicine. Personally, I think one of the most threatening parts of artificial intelligence is feeling a lack of control over your healthcare. This makes me wonder about how much autonomy patients will be given over their healthcare when using this technology. For those unfamiliar, autonomy is the right of competent adults to make informed decisions about their medical care. Because artificial intelligence algorithms can be complicated to understand, I wonder if it will be hard to understand as both a patient and healthcare provider how artificial intelligence technology is making decisions regarding diagnoses and treatment options. This may raise concerns about transparency in healthcare and the potential for patients to be treated unfairly due to possible bias displayed by the technology. Additionally, the use of artificial intelligence in healthcare could lead to the depersonalization of care, as patients may be treated more as data points rather than people. This could greatly compromise the ability to create individualized treatment plans, therefore harming the doctor-patient relationship and quality of care provided to the patient. Ashleigh Kennedy presented this perfectly when she stated: “…if we get artificial intelligence-driven healthcare wrong, we risk losing some of what it means to be human along the way.” Although artificial intelligence may offer significant advancements in medical care, those improvements are not worth it if we choose to compromise our humanity along the way. Overall, it is important to carefully consider the potential ethical issues that may arise with the integration of artificial intelligence in healthcare to ensure that patient autonomy and privacy are respected and that the quality of healthcare remains intact.

As a current medical student, I find the thought of AI in healthcare to be slightly intimidating. The thought of AI robots like Sophia largely taking over the jobs of physicians is fascinating, but also slightly detrimental to those who spend their whole life working towards this job. I really enjoy the stance Ashleigh took on the use of AI within the medical field; she did not seem to be biased for it or against it. I think it is easy to recognize the benefits these robots could contribute to the future. Physicians are overworked and the world is still ever-expanding, so at some point, we are going to need to learn how to work more efficiently, starting with artificial intelligence. Ashleigh’s examples of the bionic eye brain implant, prosthetic limb, and exoskeletons are just the start of many incredible innovations to come; however, I believe it is important to discuss the consequences of relying too heavily on AI. Ashleigh touches on the commercialization of some of these products, specifically the deep brain stimulation implants for Alzheimer’s patients. This introduces the concept of affordability within healthcare. Will products like these create an even wider division between the different economical classes when it comes to your physical health? If only the wealthy can afford these life-saving products, what good are they for the rest of the world? The principle of beneficence means the physician is obligated to act in the benefit of their patient. What happens if there is a patient who requires one of these AI technologies to survive, but cannot afford to pay for it? This puts the physician in a situation where the only beneficial option for the patient is unobtainable. If we are going to introduce new technologies, we need to make sure they are affordable and accessible to everyone, otherwise the progress we make will eventually plateau out. AI has already proven to enhance our healthcare system, we just need to be extra cautious as the technology continues to advance, making sure our patients remain our top priority.”

Ashleigh's presentation of Sophia and the concept of AI revolutionizing healthcare has been informative and entertaining. As AI has become more accessible, it is clear that such technology has an immense capacity to benefit the healthcare system. But I fear that perhaps AI is progressing too fast and is in need of further regulation before it is ready for the medical field. After all, we are as a society just starting to make use of this technology and it would be foolish to trust AI systems that we have yet to fully grasp with something as life-changing as healthcare. I understand that AI within the specific tools that Ashleigh mentioned have utility, but most of my problems with medical AI lie in the physican-patient interaction. My first ethical concern comes from the potential for patients to miss out on the best possible treatment for the sake of medical corporations saving money by replacing physicians with machines. This would violate the medical ethical principle of justice, as it would dehumanize patients and sacrifice quality for convenience. Healthcare is extremely personalized and no individual is the same, AIs in their current form would not be able to make such adjustments to tailor care to each individual patient. Patients also have a right to make an emotional and spiritual connection with their health care provider, and this is something a machine cannot provide. If Ashleigh’s prediction of the decreased roles of family physicians is true, then all of these facets of the physician-patient interaction will be lost. When it comes to accuracy, AI typically draw from a composite of existing information to make decisions, if they run across new problems, they might not be well equipped to solve them. The medical industry is constantly changing and new discoveries are made daily, what is best practice is often very subjective between physicians and I do not see how a machine is capable of prioritizing one over the other. This becomes particularly tricky when considering that ethical dilemmas occur daily within the medical field. At best, an AI would not know how to act in such a situation, but at worst it could draw its own harmful conclusions or base its decision off of some faulty or biased data. With all of this in mind, it would seem to violate the concept of beneficence to put an AI in charge of a patient’s healthcare. I am no conspiracy theorist and I am not saying that the current AI we have is comparable to the kind seen in the Terminator movies, but I feel like there are several nuances to this newfound territory that we better approach with caution, especially when people’s lives and wellbeing are at stake.

I feel that intense, progressive healthcare innovation is often met with resistance, yet medicine still seems to advance rapidly. At the beginning of Ashleigh's remarks, I felt opposed to AI in healthcare. As a medical student, I feel resistant to having AI consume a large portion of my job. However, Ashleigh went on to make a great point, that the current incorporation of AI into healthcare is a co-provider method where AI provides its insights then the final decision is made by a physician. Working alongside AI sounds like a perfect utilization of developing resources to better serve their patients. I am interested and excited to see how this technology influences my future career.

@user-is6jx5js4l

Жыл бұрын

I, too, have a similar mix of emotions when thinking about how fast artificial intelligence is advancing and how it will impact medicine. No one understands the vast impact AI will ultimately have. Ms. Kennedy spoke about a few of the ethical issues that AI is facing. The most concerning to me is the cost and accessibility of AI's services and technology. Her movie reference to Gattaca was very appropriate, but we are already living in this movie without AI. Wearables like fit bit and apple watch are expensive, making it difficult for lower-income populations to benefit from these technologies. The newest apple watch even can inform the wearer if an abnormal heart rhythm is being sensed and can call 911 for the wearer. Health care has already seen the value in these devices; private insurance companies will even buy apple watches for their patrons. Medicare and Medicaid do not provide the same benefits. I only see AI further dividing health inequality in our society. Those with access will benefit, and those who do not will continue down the path of those who suffer worse health outcomes. While this might be an inevitable outcome, Ms. Kennedy said if we get this right, we can democratize health care across the globe. AI will improve healthcare delivery and outcomes. But capitalism and healthcare have never meshed perfectly, and AI will widen the inequalities we observe in our healthcare system.

@user-pk3em5ul3j

Жыл бұрын

As a fellow medical student, I absolutely agree with you. When I was first watching this video, I was against the notion of AI being incorporated into healthcare out of fear that AI would threaten my role as a future physician. However, as I continued listening to Ashleigh’s remarks about having AI as a co-provider method, I was relieved. If AI was to be incorporated into healthcare a co-provider method where the physician makes the final decision, I would be all for it. My only question is how informed consent would work in the situation of an AI. As future physicians, we are already trained on how to obtain informed consent from our patients and must tell our patients who we are disclosing their information to. In the case of an AI being involved in patient care, would we treat the AI as another provider and have it (or us) obtain consent from the patient for it to have access to the patient’s chart and healthcare information or would we consider the AI as technology to be used to help provide better care to our patients as in the case of electronic medical records, etc.?

@jakehunsaker8838

Жыл бұрын

@@user-pk3em5ul3j That is a great question and would be something to consider as this technology progresses. I think asking patients to consent to AI usage would not be necessary at the outset of its integration into healthcare. My reasoning behind it is set in the idea that AI will be an additional consulting resource for the primary care provider to use when treating someone. Not too different from other virtual resources we already use (UpToDate, VisualDx, etc.). However, things would be very different if AI was the primary provider. I suppose we will have to see what the future brings.

@jakehunsaker8838

Жыл бұрын

@@user-is6jx5js4l R.S., as unfortunate as it is, inequalities in healthcare seem to have existed for as long as healthcare has existed. I agree that AI would not exactly help the matter, but I would like to point out another historical trend. As technology progresses, the newest thing makes the previous model obsolete and often cheaper just like the wearable tech you mentioned. So, while many may not have access to the most recent technological advances, previous models might become more accessible/available to them. With that in mind shouldn’t we continue pressing for technological advances thereby improving care for all even if it does not directly address the gap between those that do and do not have access?

@user-pk3em5ul3j

Жыл бұрын

@@jakehunsaker8838 The way that Ashleigh speaks about AI in medicine, it seems as if AI would be used as an additional resource to help physicians treat their patients. In that case, I would agree with you that AI would not need consent. My confusion stemmed from her saying that AI would be a co-provider, which in medicine, all providers who are treating the patient would need consent from the patient. Regardless, thank you for your response! I also am eager to see what the future will bring.

This is an interesting discussion that makes me slightly uncomfortable. However, this discussion is one that is necessary. Unfortunately, artificial intelligence is only going to continue to become a bigger part of our lives. The reason I said that this discussion makes me uncomfortable is that there is so much that we do not fully know about artificial intelligence. I honestly wonder if we will ever be able to know all there is to be known about artificial intelligence. It is difficult for me to feel comfortable with the idea of allowing artificial intelligence to be responsible for someone’s health and well-being when it can easily malfunction and possibly do something that was never thought about or taken into consideration. I understand that it also has the potential to transform healthcare in many positive ways and may even be better at providing accurate diagnoses. Before I can even attempt to consider artificial intelligence as an option in healthcare, I would like to see a thorough discussion of the ethical considerations and concerns surrounding artificial intelligence in healthcare. One of the pitfalls that we have seen with other artificial intelligence programs is bias. Healthcare continues to have many unresolved biases. I am afraid that artificial intelligence will simply reflect and possibly amplify the existing biases. This can easily have serious consequences for the well-being of groups that are still discriminated against. A serious discussion about this needs to happen so that the necessary steps to avoid this pitfall can be taken. The other concern that I have about artificial intelligence is its ability to operate within the important principles of beneficence, non-maleficence, and respect for autonomy. It is difficult to believe that a software would be capable of truly understanding the weight of these principles and ensuring their continued adherence. How would we ensure that artificial intelligence in healthcare can be guided by these principles?

If AI is considered to be more capable at providing healthcare, then I believe that it would be causing harm by withholding this technology from treating patients. If it is more superior in thought and practice of medicine, then having a human who will inevitably cause harm through its inperfect practice would be breaking the ethical code of acting in the patient’s best interest. As a future physician, this frightens me in regards to my job security, but I believe that this is a selfish thought. If it were my own family member or myself who were in dier need of healthcare and I knew that AI would produce better results, I would want to use that technology. As Ashleigh noted there would be safeguards that would allow for the “physician” to have the final say in the care. I do belive that some oversight would be required at first, but what if we found that the AI was completely capable of providing medical care and did not require oversight? Would the physician then become obsolete? In addition to this, would the physician be the best person to oversee the AI? If the AI understood medicine better than the physician, then I believe that the IA should be used as a tool to oversee the physician. Another aspect that I believe could be utilized with this technology is to help reduce the burden of physician burn out. theoretically, this technology could help change the rigorous medical training that causes so much despair in training and practicing physicians. Imagine if instead of 10 years of medical training, the physican had some of the memorizing burden taken off their shoulders through the use of AI. Instead, the physician could be trained in a shorter amount of time on how to use AI to get their job done. I believe that this would also be ethical in that it would help reduce the rate of physician suicide and help reduce physician burn out in general. This would allow for better care and more people wishing to peruse this otherwise too rigorous job.