The Power of Heredity and the Power of Environment in Raising Children

2020/04/14

As a pediatrician, most of the people I meet through my work are children and mothers, and occasionally fathers. Therefore, what I will speak about today consists entirely of things I have learned from children and their parents.

Today, I will first talk about the "power of heredity." In fact, whether it is for a magazine article or a lecture, I am often asked not to use the word "heredity" in the title. It seems that in the eyes of the public, heredity carries negative images such as "discrimination" or "something irreversible." Therefore, I would first like to clear up the misunderstandings surrounding the word heredity.

Next, I will talk about the "power of the environment." Even when we simply say environment, there are various types, such as the child-rearing environment, home environment, school environment, and social environment. I would like to talk about how strong, wonderful, or precarious the power of that environment can be.

And finally, I will talk about being an "advocate." As a result of doing my work in my own way, I have reached the conclusion that those who are pediatricians—and furthermore, all adults—should be "advocates for children." I would very much like to convey that to everyone.

Now, before getting into the main topic, please let me talk about "modern pediatrics."

When I became a pediatrician, pediatrics was a field of study for curing diseases such as infectious diseases that children encounter in the process of being born and growing up. However, before I knew it, pediatrics had made rapid progress as a science and had completely changed. As is the case with all medical sciences, the role of pediatrics as a social and human science has come to be emphasized, not just its perspective as a natural science.

First, pediatrics as a natural science aims to scientifically study the process by which the human body is formed (growth) and the process by which functions take up residence there (development), identify the causes of abnormalities in those processes, develop treatments, and actually perform those treatments. Pediatrics is the "science of growth and development." The process by which children grow and acquire abilities has been studied for a long time, but it had not reached the point of deep scientific understanding. However, now, due to the progress of science, the mechanisms of growth and development are being elucidated at the cellular level. The mechanisms of morphogenesis and functional acquisition are being revealed—how featureless cells gradually take shape, for example, muscle cells becoming able to move, or nerve cells becoming able to generate electricity. As a result of the dramatic progress in basic medicine, pediatrics as a natural science dealing with growth and development has also achieved great development.

Next, let's consider the current position of pediatrics from the aspect of social and human sciences. When you read the newspaper, it is full of topics regarding the environment surrounding children, such as abuse, poverty, and bullying. And I think a force is welling up in society as a whole to do something about it. Within that, healthcare professionals should also be a profession rooted in society, and there must be a role for pediatricians to play there.

I realize that even children who look healthy at first glance, and even children who look happy at first glance, are all living while carrying some kind of difficulty. This is an important thing I have learned from children over more than 30 years as a pediatrician. I think it is important to have the mindset that there is no such thing as a truly happy child.

There are children living with innate difficulties due to genetic abnormalities or problems at birth. There are also children facing difficulties such as waking up one night, going to the kitchen, and seeing their father hitting their mother. Or, if the economy worsens and a father is laid off, the family situation changes suddenly. Of course, even a simple cold is a major event for a child.

The mission of modern pediatrics is to lend strength to overcome the mental and physical difficulties that children face. What is its purpose? Overcoming illness and achieving growth and development is not enough. Even if an illness cannot be overcome, or even if there are obstacles to growth, I want all children to obtain a happy life. That is the ultimate goal of pediatrics. And thanks to the progress of science and the maturity of society, I believe that achieving such a goal is no longer just a dream.

Here, let's think about "heredity" and "environment," which are the themes of today's talk. "Scientifically studying growth and development" is a natural science that begins with elucidating the role of genes. On the other hand, "leading children to happiness" is nothing other than a social science that improves the environment surrounding children. In other words, modern pediatrics is a science that approaches heredity and environment.

The power of heredity is the "power to protect," and the power of the environment is the "power to nurture"

In a person's life, which power is stronger: heredity or environment? Shortly after birth, most things are determined by the power of genes. On the other hand, the power of the environment is not so great when one is a baby, but it gradually becomes stronger. By the time one reaches old age, the results of the experience, knowledge, and effort accumulated until then create daily life and one's path.

I think the fetal environment is one of the greatest concerns for mothers and fathers during pregnancy. To state the conclusion, the fetus is protected almost 100% by the power of genes. Environmental factors cannot easily influence the process by which a baby's body is formed and functions take up residence in the womb. Therefore, unless it is a case such as being exposed to a large amount of radiation or being continuously tormented by extreme violence or depression, as long as the mother looks forward to the birth and lives a normal life, things will not go wrong so easily. This is a very important message of mine today.

Let me introduce a story that actually happened. One baby, unfortunately, was slow to walk. At the health center, the parents were told, "There is a suspicion of cerebral palsy, so have the baby examined at a university hospital." When I examined the baby, it was indeed a mild case of cerebral palsy. When I told the parents, they said, "There must be a cause." Then, the grandfather and grandmother said, "Maybe it was because she took a plane to visit her hometown during pregnancy, thinking it was the stable period."

However, that is completely groundless. When people hear the word heredity, many seem to have a negative image, such as "it will never be cured" or "effort is useless," but in fact, by being "unchanging," it protects us, including during the fetal period. Whether you drink a little alcohol in early pregnancy or travel by plane, it has no effect on the fetus. If you ask a doctor on the spot, we can tell you "it's not related," but it often becomes a family consensus that "it was that, wasn't it" or "let's keep it a secret."

The most pitiful thing in this story is that the mother herself becomes convinced that "it's because I took the plane." That is what motherhood is. It is a painful and warm instinct to blame oneself, as a mother, for all the misfortunes and difficulties that happen to a child. I have worked as a pediatrician wanting to somehow clear up that misunderstanding.

Regarding the power of heredity, another important thing in addition to it being unchanging is that, especially in the growth and development of a baby, it does not presuppose actually experiencing something or making an effort. We are not taught by anyone, nor do we learn from experience, how to smile or stand on two legs. The powers that are absolutely necessary for a human being to live are always acquired according to the scenario prepared by the genes.

In contrast, environments such as the home and school are rich in change, uncertain, and fluid. That is exactly why the "power of the environment" becomes the "power to nurture." And the point that is decisively different from heredity is that for the environment to exert its power, it is absolutely necessary to actually experience it.

Genes are there without being experienced and protect us unchangingly. The environment exerts its power only through experience. These two powers protect and nurture children while maintaining a balance.

The job of genes is to make proteins

Now, humans have about 20,000 genes, but this is not necessarily more than lower animals or plants. So, what are those 20,000 genes doing? Almost all genes are blueprints for making proteins. They connect many amino acids to make proteins.

A characteristic of proteins is that they always have a three-dimensional structure. And by this protein and that protein combining and moving, muscle cells are made, or when these proteins combine, positive ions flow in to generate electricity and nerve cells are created. Our bodies are built by creating countless proteins with the correct shape, and by functions taking up residence where the shapes are correctly made.

I mentioned "morphogenesis and functional acquisition" earlier, and that process can be said to be exactly the process of making proteins according to the blueprints following the genetic scenario, and functions taking up residence there. We build our bodies according to the blueprints determined by our genes and live by acquiring the functions essential for a human being.

Individuality is variation

Here, please look at two graphs (Figure 1). There are three bundles of curves, with seven lines per bundle. All of them show the growth process of boys from age 1 to 18. The top of the left figure shows height, the bottom shows weight, and the right figure shows the normal values for head circumference. When there are seven lines like this, people tend to misunderstand that the average value in the middle is normal and that the further away you get from it, up or down, the more abnormal it is, but that is a big mistake. The range indicated by the double-headed arrows—that is, all seven lines—are normal values. Of course, as you know, there are cases where the environment has an influence, such as getting fat if you eat a lot or getting thin if nutrition is insufficient.

Figure 1: The process by which the body is formed (growth)

Height, head circumference, and to some extent weight—many parts related to growth are determined by genes, but the scope of those genes is surprisingly wide. There is always "variation" in what is normal, and we call that individuality. Care is needed so that this individuality is not mistaken for illness or abnormality. I believe that we doctors, as experts, have a duty to clearly explain to children within the normal range that "it is within the range of individuality."

Next, let's look at the variation in the process by which functions take up residence, "development" (Figure 2). The horizontal axis of the graph represents the 12 months after birth, and the upward-sloping straight line shows the functions the baby acquires during that time. This is a diagram I always use in classes at the School of Medicine, and it is so important that it appears on the National Examination for Medical Practitioners. Even if one does not become a pediatrician, any doctor needs to understand the development of a child during the first 12 months of life.

Figure 2: The process by which functions take up residence (development)

Looking at the 12-month mark, it says "meaningful words," "standing," and "thumb opposition." Meaningful words means being able to say words with meaning. Saying "mamma" for food, or calling Anpanman "Npa." It doesn't need to be accurate; the acquisition of language that is meaningful as a name for that child happens around the 12th month.

"Standing" means standing up on two legs. The smile of a child when they first let go while cruising and stand on two legs. "They smiled broadly with a face that said 'I did it!'" Many mothers answer happily. That moment is an unforgettable anniversary for a mother. Because mothers remember all those moments, their hard work in child-rearing is rewarded and they can be happy.

"Thumb opposition" means picking up small objects using the thumb and index finger. If it is a large object like a cup, they can grab it with their whole hand, but if they want to pick up a hair on the floor, they must oppose the thumb and index finger and pick it up like tweezers. It is said that only humans can do this, and they become able to do it around one year of age.

In other words, humans acquire three abilities that other animals cannot imitate—"communication through language," "bipedal walking," and "fine motor skills of the hands"—in about 12 months after birth. That process happens step by step. For "standing," they can hold their head up around three months, sit up at about half a year, stand while holding on at around nine months, and stand on two legs after one year.

What I want to emphasize here is the horizontal double-headed arrow on the diagonal line. Not everyone moves to the next step at exactly 3, 6, 9, and 12 months; the timing varies depending on the child, and all of them are normal. In other words, just like the growth I introduced in Figure 1, variation and individuality are woven into development as well.

Furthermore, this horizontal width becomes wider as it goes toward the top right. In other words, simple things like "holding the head up" or "opening the hand wide" can be done at three months plus or minus about one month, but for bipedal walking, there is a range of several months. These are, of course, all normal. In the developmental process, the more advanced the ability, the greater the individual difference in the timing of when it can be done.

Variation in the developmental process is also mostly determined by genes. Therefore, even if you force a child to sit up, it does not mean that subsequent development will proceed faster. Also, even if they can sit up early, it does not mean they have good motor skills. Being able to do something early is unrelated to being able to do it well. Whether it is early or late, it is nothing more than normal variation determined by genes. Note that judgments such as "it's okay to be this late" or "it's possible to do it this early" might be difficult for anyone other than a pediatrician.

Genes are notes, people are scores?

Why is rich individuality expressed even though we are human beings with almost the same genes? Here, how about likening each gene to a musical note and the "human blueprint" created by 20,000 genes to a musical score?

For example, a piano has 88 keys, but if you use 88 notes, you can compose countless pieces of music. Suppose that one of them, "Air on the G String," is the human blueprint. In other words, among countless biological species, all humans are "Air on the G String." However, the one who performs it is you. One person performs it in an orchestra, another person sings it. In that case, even if given the same score, depending on the performer, it will become a completely different song... well, even if it doesn't, it will become a piece of music full of variety and individuality.

In other words, I think that the fact that there is variation in height, weight, or the developmental process even though the genes are almost the same is something like the impression of a song being greatly different depending on the performer even if they are handed the same score.

On the other hand, there are babies born with a certain note missing from the score, or in terms of an instrument, a certain sound not coming out—that is, an abnormality in a specific gene. However, humans also have this kind of strength. For example, there are not many songs that do not use the "C" in the middle of a piano keyboard, but suppose there was a genetic abnormality where only this "C" sound does not come out. The other 87 keys are fine. This is a state called a single-gene disorder. So, what happens? Even if you perform skipping the "C," it works reasonably well, and you can get through it by using chords instead of "C" or by arranging the piece. It is surprisingly common to be able to live without problems even if there is an abnormality in a gene.

The educational environment is paternal

In addition to the fetal environment I mentioned at the beginning, there are various environments such as the home environment, child-rearing environment, school environment, and social environment. Among them, I feel that the educational environment is "paternal." This is my own idea, but a characteristic of fatherhood is the power to act systematically based on data such as average ways of thinking, standards, and rules in the world. "Think about it carefully," "Generally in society..." and so on. And education needs a goal, an outcome, of "what kind of person we want to raise." Setting goals and letting them experience various things efficiently based on a lot of data while following a standard approach. I think this is closer to a paternal way of thinking rather than maternal.

By the way, motherhood is more intuitive. It tends to leave judgment to whether one felt it was good or not, rather than whether it was correct. Decisions are made simply with "But look," or "Even this child is saying so." Of course, it goes without saying that the balance between motherhood and fatherhood is important in the field of education as well.

Here, let me emphasize that motherhood does not necessarily equal female, and fatherhood does not necessarily equal male. Suppose a certain woman is usually 90% motherhood and 10% fatherhood; through childbirth and child-rearing, motherhood doubles, but fatherhood stays the same, so the total rises to 190%. Later, when she returns to work, fatherhood increases, and when she is promoted to department manager, fatherhood becomes 50%, making the total a whopping 240%. The same goes for men; I think a husband who was devoted to work might see his motherhood grow when he is blessed with a child. Both women and men can use motherhood and fatherhood differently in various scenes of life and nurture themselves.

The power of education is equal

Now, do you know the name of the disease "dyslexia"? It is a type of learning difficulty where, despite being a hard worker and being able to study, the person is only poor at reading and writing. This difficulty is determined almost entirely by the power of genes. Therefore, they study hard and can do other subjects, but they are completely hopeless at reading aloud in Japanese class. Also, there are even more people who are not good at reading, even if it is not to the extent that it becomes a major problem in school life. Actually, I also hate reading papers. But when I hear stories from people who have read the papers, it enters my head smoothly through my ears.

Here, look at Figure 3. In this graph, the horizontal axis is the child's age from 6 to 16, which corresponds to the period of elementary and junior high school. The vertical axis is the ability to read text. Let's call the child on the upper curve who is good at reading and writing Boy A, and the child on the lower dashed line who is poor at reading and writing Boy B. First, looking at Boy A, who is good at reading and writing, he grows rapidly during elementary school. However, it levels off once he enters junior high school. We can see that reading aloud a lot in elementary school is indeed important.

Figure 3: The wall of heredity and the effect of education

On the other hand, as for Boy B, although he worked hard in elementary school, he could not catch up to Boy A no matter what, and he could not close the gap after that either. Since the ability to read has a strong element determined genetically, we reach the conclusion that there is a wall that cannot be caught up to even with effort.

However, looking at the six years of elementary school, we notice that the way the scores increase for both Boy A and Boy B is almost the same—in other words, the educational effect is the same. That's surprising. Even if there are innate strengths and weaknesses and walls that cannot be crossed, education brings similar effects to both. Working hard at something during a certain period is never in vain. How meaningful was the homework in childhood to "read aloud three times at home and get a signature from your mother." I finally understood it at this age. This is the power of education.

Furthermore, in recent years, training to overcome this gap is being developed in the United States. This means that if science advances further in the future, the possibility has emerged that at least for things like reading and writing, genetic walls can be overcome through training—that is, the power of the environment called education.

Overcoming genetic walls with the power of the environment

Here, let me talk about a baby who is a patient at Keio Hospital. We are providing so-called gene therapy to a baby with a disease caused by a genetic abnormality called spinal muscular atrophy. We insert a needle into the back and inject medicine into the spinal fluid, and by repeating that every few months, not only is the life of the child, who was supposed to die soon, saved, but walking is no longer a dream. This is a miraculous drug, and it is nothing but a victory for the "power of the environment called science." For the father and mother, an unbelievable phenomenon occurs where a child they thought would die without being able to walk starts walking with a smile.

Furthermore, in that the treatment can be received without financial burden on the parents, it is also a victory for the medical insurance system—that is, the "power of the environment called society." This is because one dose of this medicine costs 10 million yen. Furthermore, a drug has also been developed for the same disease that requires only one intravenous injection for a lifetime of treatment. It is a drug that saves one life and gives the gift of a long, happy life. This drug costs over 200 million yen, but it is also covered by the medical insurance system.

What I wanted to convey here is the fact that we have entered an era where even genetic diseases that were thought to be absolutely incurable can be cured—that is, the reliability of the "power of the environment called science"—and the fact that the country of Japan thinks it is okay to pay 200 million yen to save the life of one child and protect the happiness of that family—that is, the generosity of the "power of the environment called society."

The negative power of the environment

The environment also has negative aspects. Currently, with the spread of the internet and smartphones, it has become a major social problem that children get hooked on SNS and online games. What is bad about this media environment? I think it can be summarized into three things. The first is "silencing," where conversation disappears. The second is "isolation," where time spent alone becomes longer. And the third is the "decrease in real-life experiences."

I think you all understand silencing and isolation. For example, a mother and her middle school son are eating dinner. The child has chopsticks in his right hand and a smartphone in his left. The mother wants to have a conversation like "How was school?" but she also has her smartphone placed by the table. Then, the smartphone vibrates. Thinking "Maybe it's the father, or the PTA," she looks, and it's a LINE message from the son right in front of her (laughs). What should she do? Probably, the mother opens it. Then, it says "Today's pumpkin is super tasty" (laughs). The mother gets happy and replies via LINE. "This is called chestnut pumpkin, and it's in season now," or something like that. It's a good example of silencing.

Now, the biggest problem is the "decrease in real-life experiences." As I said at the beginning, for the environment to exert its power, it is necessary to actually experience that environment. For example, if you scratch a friend's face at nursery school, the friend starts crying. You get scolded by the teacher, feel sad, and tears fall. And the next day, your mother is called, she apologizes to the nursery school teacher, and your mother is also crying... Such real-life experiences are extremely important. Just the words "You must not hurt people" are not enough. It is important to experience for yourself what happens if you hit someone. We should avoid serious accidents, but we enjoy the benefits of the environment by accumulating real-life experiences of small failures.

And on the way home, your mother holds your warm hand. You promise "I won't do it again." The autumn leaves were beautiful, a slightly cold wind blew, and it felt very good. This is a real-life experience. Such experiences are taken into oneself—that is, internalized—and as a result, imagination is nurtured. Then, the child will find solutions even for problems they face for the first time. The driving force for judging "I shouldn't do this" is, in many cases, the power to imagine that "If I do this, my mother will be sad" or "I will be scolded by my father."

Also, the power to expect something from another person's heart, like "If I do this, they will surely be happy," is nurtured by real-life experiences. Or, one becomes able to sense in advance that the other person will be hurt, just through imagination, like "If I say this, they will surely be sad. I'll refrain from saying it."

If imagination is nurtured based on many real-life experiences, virtual reality will also become meaningful. However, neglecting real-life experiences and creating the illusion that one has experienced things that do not exist is dangerous, at least for children. Through competitive online games, outrageous "experiences" such as people coming back to life even if killed, or getting points for hitting an opponent, could end up being internalized.

A poor child-rearing environment caused by a lack of motherhood

In a poor home environment lacking motherhood, or in a hospital life that cannot be called healthy, how does the power of genes fight against the negative environment and protect children? I would like to think about this together through the story of a boy who was hospitalized at our hospital.

That boy had not grown in height since around age three, and furthermore, when he was brought to the hospital after turning four, his weight was only about that of a two-year-old. The diagnosis was psychosocial dwarfism. The cause was a lack of motherhood.

Food was provided, there was a house, and there was a bed. There was no father. However, the mother did not feel that the child was her own. Even though she understood it in her head, she could not love him no matter what. Something was strange about this child. He never smiled. Depending on how you look at it, this mother was great. I think it was good that she brought him to the hospital.

The first thing we did was a treatment called mother-child separation, separating the mother and the child. The child was hospitalized and forbidden from having visitors, and the mother received treatment from a doctor as an outpatient. The mother did not improve at all. On the other hand, the boy, who at first would not even make eye contact, gradually improved in his interpersonal relationships, and both his height and weight increased significantly.

During that time, all we did was have a nurse or a young pediatrician sit next to him for three meals and have conversations like "That looks delicious" or "I told you not to play on your friend's bed." This was because this child would get bored and go to other children's beds to play. However, for infection control, patients are prohibited from climbing onto other beds.

Now, an older girl was hospitalized in the same room. The girl was very maternal and kind, as girls often are. She would play with him, asking "Want to play Othello?" He couldn't help but have fun, so he would go again. The girl would say, "You're here again. I wonder if you're eating properly?" But after a while, she would say "Go away for now!" or "Don't come anymore!" Soon, the girl's hair fell out, she became pale, and she kept vomiting while connected to an IV. Since she was hospitalized for leukemia, she couldn't stay energetic forever. This is what a hospital is like.

Also, in the bed by the window, there was a boy who had just started first grade. He had aortic valve disease of the heart and was diagnosed with about one year to live unless he had surgery. It was advanced heart failure. On the other hand, because he had a history of myocardial infarction, there was a several percent chance he would not return from the operating room. There was a 20-30% chance he would lose his life within a year after the surgery. That child screamed, "I absolutely hate surgery!" This is because he had suffered many times before with cardiac catheterization and other surgeries, and he knew the fear of being locked in an intensive care unit for a week or two.

However, in Japan, children under 15 do not have the right to decide yes or no. If the parents sign the consent form, the surgery is performed regardless of the child's will. Of course, that is done with the child's life in mind, and in a sense, it is the right thing to do. However, recently I have come to think that I should have talked more with that child. I should have talked more at that bedside from the same eye level as him and repeated the persuasion. I truly reflect on it and regret it.

That older boy did not return from the operating room. Even that child hospitalized in the same room for psychosocial dwarfism noticed. "Big brother isn't coming back. He died." That big brother he was close to disappeared like that. Even so, the hardest thing for this child was seeing off the children who got well and whose fathers or mothers came to pick them up for discharge. After seeing off many such children, this child was hospitalized for over a year. Were we able to give motherhood to this child?

Parent-loving genes that stand up to a poor environment

After that, he became a "normal boy" who had fully increased in height and weight and laughed energetically, and the time for discharge came. Then, where to? He went to a children's home. He would start a new life there. Without meeting his mother at all, he also left the facility on the day of his elementary school entrance ceremony. However, his mother appeared at the school gate.

The primary doctor treating the mother had judged that it was about time to let her see her son. Surprisingly, the boy, meeting his mother for the first time in several years, reportedly said, "Mom, I'm so glad for you." Actually, when the boy was discharged, the primary doctor made an excuse. "Your mother has a serious illness. That's why you can't go home yet. Let's live with friends until your mother gets well." The boy accepted this and went to the facility.

The fact that his mother appeared at the school gate meant that her illness was cured. He understood that instantly. That's why he said, "Mom, I'm so glad for you."

Everyone, can you believe it? For the first four years of his life, he was never loved, never touched by motherhood, was emaciated and didn't grow in height, was left at the hospital just like that, and then left at a facility. Even so, he lived at the facility thinking, "Mom is sick. I have to be patient for now," and "I want Mom to get well." The feeling of a child thinking of their parent can only be thought of as the work of genes. Protected by the power of genes that are not influenced by experience, no matter what happens, a child will not betray their parent. I see, I thought.

I feel that power of genes most strongly when a child becomes a victim of abuse. A child whose big toe is bruised and whose nail is crushed. Probably, it was squeezed with pliers. Also, there was a child whose head was tightened with a vise. There was a child who was put in a black plastic bag and shot with an air gun. However, these children who are victims of abuse never reveal that their parents did it. Almost without exception, they insist, "I did it myself."

There was a child who was made to write a letter before being killed, wasn't there? Saying "I was bad, Dad is not bad." This is my speculation, but I don't think such letters were necessarily forced. They must have been brainwashed. This is because there is something like an instinct that a father or mother could not possibly do such a thing to them. They become convinced that it must be their own fault. If they are told, "It's your fault. Dad is doing this to educate you," they really think so. The feeling of a child thinking of their parent is protected by the power of genes and is very strong. Adults must never take advantage of that strong and warm feeling.

The power of the environment that even twists the power of heredity

On the other hand, even such strong genetic power can be distorted by the power of the environment. Actually, when he was hospitalized, this boy's head circumference—that is, his brain—was small. It grew significantly after hospitalization. Actually, this is a strange thing. For example, children suffering from hunger in Africa are emaciated from the neck down due to malnutrition, but their head size is normal. Also, even if placental function drops during pregnancy and nutrition reaching the fetus is insufficient, the brain is born with a normal size. No matter the adversity, the body is made so that the blood with the most nutrients flows to the brain.

However, in an environment without motherhood, the brain shrinks. As I said at the beginning, the process by which shape is made and correct functions take up residence there is protected by the power of genes. However, a home environment without love was twisting even that. The boy's brain grew gradually during his subsequent hospital life, and I think that on the day of the entrance ceremony, the "parent-loving genes" bloomed at the perfect moment and made him say the words, "Mom, I'm so glad for you." The size of the head—that is, the size of the brain—taught us various stories.

Pediatricians are "advocates of motherhood"

Finally, I will talk about being an advocate. First, the story that we pediatricians are advocates. Curing diseases is not our only job.

Originally, the idea of an advocate (Advocator) came from the American Academy of Pediatrics. Specifically, it is an advocate who reflects the thoughts of children who cannot speak, or young fathers and mothers, in politics, or appeals widely through the media. I call the advocate they speak of a "paternal advocate."

In that sense, the "public speaking" around the 7th year of Meiji, which Yukichi Fukuzawa started as a way to convey his will to many people by saying "Let's try it with spoken words instead of documents, it should be possible even in Japanese," was, I think, an attempt to become a paternal advocate.

On the other hand, I think being an advocate has an aspect of being an "advocate of motherhood." I believe that pediatricians are required not only to exert fatherhood but also to exert motherhood and become advocates for children and their families.

"Listening skills" and "persuasive power"

To become an advocate of motherhood, two powers are essential: "listening skills" and "persuasive power." "Listening skills" (傾聴力), as the character for "listen" (聴) suggests, is the power to listen carefully, watch closely, bring one's heart close to the other person's position, exert empathy, and draw out information. This is the same in internal medicine or surgery where adults are treated, but especially in the case of pediatrics, the counterparts are children who cannot well grasp the difficulties they are facing, or who cannot even correctly understand the fact that they are being abused. Or, it is a mother who cannot understand the reason why her husband raises his hand against the child, but has no choice but to watch over it. Those difficulties are hidden within things they are forbidden from saying, things they are too ashamed to say, or things they answer haphazardly because they think they are not important. The power to correctly and firmly draw those out is necessary, and that is called listening skills. This can absolutely never be acquired without the real-life experience of clinical practice.

Next is "persuasive power," but there is one thing to do before that. That is the act of "judging." There are actually only two things that a doctor judges or decides. Making a diagnosis and establishing a treatment plan (including the decision not to treat). You must not leave the judgment to the patient. There seem to be cases where it is considered good to present two or more treatment methods and let the patient choose "Which one will you choose?" At first glance, it seems fair, but I think in many cases it is something that should be avoided. After listening sufficiently to the story, the doctor should choose the best treatment for that patient. Once decided, there is an obligation to persuade the other person about it. That is our job as doctors. I think that is what "independence and self-respect" (独立不羈) means. Think for yourself, decide for yourself, and put it into action. To have the patient be convinced of what you have judged yourself, "persuasive power" becomes necessary.

To persuade a patient, various powers are needed, but first is "listening skills." In other words, they felt their story was heard with "I see, is that so?" The suffering they didn't know how to express themselves was translated as "Is it this kind of thing?" In a dialogue with a doctor they met for the first time, if they are convinced that "This doctor is really listening to my story," "Come to think of it, my vague anxiety was that," and "This doctor can be trusted," I think they are ready to accept the diagnosis and treatment plan at that point.

Conversely, medical care that hands over test data, reads out explanatory documents, and asks for a signature—reverting to communication through documents before "public speaking" was born—will not be permitted in the future. Obtaining consent through documents is something even AI can do. Also, diagnosis and determination of treatment plans based on data can mostly be settled by AI. However, can you accept what an AI decided, especially a harsh diagnosis or painful treatment? Isn't it because it was explained face-to-face one-on-one, discussed, and as a result, were words that came from the doctor, that you can be convinced?

Reassuring someone is difficult

Let me introduce an episode that made me feel that being an advocate of motherhood is more important than anything else.

A six-month-old baby who suddenly stopped moving his right arm was brought to our hospital. And when we took a CT scan of the brain, there was a shadow in the right cerebrum, and we jumped to the conclusion that it was paralysis caused by that. However, if the right side of the brain is damaged, there should be paralysis on the left side. The answer was simple: a "spiral fracture of the right humerus." The father had twisted and broken it. If you took off the clothes, there were many bruises. The mother knew that from the beginning and rushed to the hospital in the middle of the night seeking help. What on earth is the point of doing things like brain CT scans? If the doctor had the listening skills to draw out the mother's plea that "My husband's abuse is continuing. Please help me," we should have been able to protect them immediately without unnecessary tests.

By the way, everyone, can you imagine what the most difficult illness to persuade someone of is? It is "health." Persuading someone that "you are not sick" is the most difficult. They come to the hospital because they are worried, yet you tell them "You're not sick," or "Please rest assured because treatment is not necessary." I call this the "devil's proof" in medical care. Because proving that something that isn't there isn't there—that there is no devil—is a very difficult thing. Everyone, if there is a doctor at a hospital who kindly persuades you, saying "Please rest assured. Treatment is not necessary," "But I have symptoms. I'm worried," "I understand, however..." that doctor might be a great one.

A doctor with persuasive power gives the patient a sense of security the moment they meet. Persuasive power is a very important power for a doctor. At 2:00 AM, seeing the number 40.6 degrees on the thermometer. A mother presses 119 for the first time in her life and calls an ambulance. In the emergency room in the middle of the night, the most important job for a doctor is to warmly welcome the parent and child as an advocate of motherhood and give an explanation they can be convinced by. It is to give a sense of security that "Oh, I'm glad it was just a cold. I'm glad I plucked up the courage to call an ambulance. I'm glad I was seen by a kind doctor." One must never say things like "Don't use an ambulance, come in your own car," or "It's just a cold, you could have waited until tomorrow morning." Even though I know this, I have repeated such mistakes myself.

All adults are advocates of motherhood

How can one become a doctor with persuasive power who can give a sense of security the moment they meet? I mentioned earlier that to persuade, listening is first necessary. I state in classes at the School of Medicine that there are two more important things. First, choose a job you can have "enthusiasm" for. Only when you have the feeling that you want to continue working with enthusiasm for 30 or 40 years—as a pediatrician if you are a pediatrician—can you speak with persuasive power. This is something even a novice doctor can do. However, there is one more thing that a young doctor absolutely cannot get right away. "Experience." If my talk has even a little bit of persuasive power, it is only because it has the backing of telling stories from decades of experience.

Then, what kind of experience should one gain? Is a doctor's persuasive power cultivated by diagnosing difficult diseases, treating serious illnesses, or accumulating many success stories? No, a doctor who is convinced they have only accumulated success stories can only tell boastful stories. Boastful stories have no persuasive power. It is in stories of failure that there is persuasive power. Of course, one should avoid making big mistakes with patients, but what is important is not to overlook small mistakes made unconsciously (called "near misses"). That mother who said anxiously earlier that "the child won't move his arm." If I had looked at her face carefully and said, "Mother, you have a bruise on your right cheek. Is your husband left-handed?" Because mothers are also sometimes hit. If there was such attentiveness and consideration, and if I could reflect that it would have been good, that becomes a very good experience. One accumulates such "negative experiences" bit by bit.

I think there are many small failures in your child-rearing as well. There is no such thing as perfect child-rearing. "Oh, I shouldn't have scolded them," "I let them eat that," "I let them get injured"... The accumulation of such small failures, and the kindness of looking back and saying "I have nothing but regrets about you..." becomes persuasive power toward the child.

Finally, I will state what I wanted to convey most today. I want all adults to become advocates of motherhood for children. All adults should have "kindness that stays close" and empathize with all children. "Listening" to children means that kind of thing. On the other hand, things that must not be done, things that should be done, discipline, education—these are things adults should decide, and there is no need to do whatever the child says. It is enough if what the adult decided is the product of kindness that stayed close to the child. If so, you can also interact with the child with confidence, and the children should also be convinced. If all adults join forces saying "Let's be good advocates for all the children we meet in the world," I believe a society will be promised where all children can obtain a happy life, no matter what difficulties they may carry.

Thank you for your attention.

(This article is based on a lecture at the 709th Mita Public Speaking Event held on November 26, 2019, with some additions and corrections.)