I do pretty much as Barbara Wilson Clay in getting consent to inform  
physicians/midwives or other hcp's of our consult. It is part of my consent  form and 
I don't even touch a baby until I have it signed. I do send reports  to HCPs 
also.   Sometimes it is a simple form I use that lets me  check off what we 
covered.  If it is something I want mom to discuss with  hcp also, I say that I 
asked her to discuss it with hcp. I have occasionally  (although it is rare) 
heard back from the hcp's about the consult. ( I really  like BWC's method 
though.  Will have to make a template and get an online  fax, that would save me 
lots of work writing, copying, faxing, mailing, etc.  Thanks for the 
information.) I do work with some clients who do not have an  official hcp.  They do not 
use pediatricians or ob/gyns.  This is  still a free country and we do not 
have to use standard medical care if we  choose not to.  For them, I report to 
whoever is handling their health  care. If it is no one, and sometimes it is no 
one, I have no one to report  to.  I have not seen anything in our code of 
ethics that states I must  refuse care to a mother who does not choose to use 
standard medical care.   Perhaps there is something there, and I just did not 
interpret it as such.   I also notice in IBLCE's Code of Ethics it states IBCLCs 
are to:
 
"23. Require and obtain consent to share clinical concerns and information  
with the physician or other primary health care provider before initiating a  
consultation." 
 
 But, it does not state the information MUST be shared, only  permission 
given to share it.  

In ILCA's Standard of Practice it  only states to communicate to health care 
providers as appropriate.  Again,  it does not state "MUST" report to hcps.  
Who determines when it is  appropriate?
 
Depending on your interpretation, that does not necessarily mean LCs must  
report every single visit to a doctor or other health care provider.  And,  from 
what I am reading on Lactnet, that certainly will vary by country -- and  the 
"I" in IBCLC stands for International, so we should take into account that  
the whole world is not as messed up as the USA when it comes to breastfeeding  
care. 
 
However, I have no problem with making it obligatory to report to a hcp all  
visits. I can see the marketing potential.  I usually do so unless the  visit 
was something so simple as a quick fix of position.  I have never  interpreted 
the current documents to mean absolutely must report every single  contact to 
a doctor.  LLL Leaders do not have to report to a hcp when they  provide 
phone help or help a mom, so I find it odd that an LC would have to  report to a 
doctor when the issue is not a medical issue.  Breastfeeding  for the most part 
is not a medical issue.  I can't imagine most doctors  care much if mom's 
sore nipples are better now because the latch was  improved.  I report mostly out 
of my own desire to market myself and to  have my name known.  It works 
because I do get calls from moms who were  told by their pediatrician to call me, 
and I know I recognize the name as one I  have sent a few reports to. 
 
My concern with the new Scope of Practice is not the idea of reporting,  
though I do think that as a global organization we need to respect global health  
care systems.  And, I do not think every single visit needs to be reported  to 
a doctor.  Though I do think it is important to work with doctors when  
medically necessary.  I also think that what is about 'breastfeeding' is  something 
unique to lactation consultants.  I do not think our scope of  practice 
should include medical procedures, though I think that term needs  defining as I 
can see using an SNS could be interpreted to mean using a medical  device.  So 
could using a nipple shield, or finger feeding with a  syringe..heck just 
feeding seems to be within the pediatrician's scope of care  as they choose formula 
for their patients.  Yikes.  Maybe we are in  more trouble than I even 
thought.
 
I think our scope of practice should be limited to all things related to  
lactation.  Of course, lots of things relate to lactation, but surely not  
assessing vaginal repairs or surgical incision healing or whatever other things  
were listed as things they have heard of LCs doing.  I never heard of these  
things, so maybe that was the issues that encouraged a more defined scope of  
practice.  I also prefer to see the scope tell us what we "can" do, not  what we 
cannot do.  To be told I cannot refer to CST (alternative),  homeopathic 
physician (alternative), chiropractor (alternative) as an option for  care is beyond 
what I expect within a scope of practice.  The idea of  alternative varies 
country to country, and actually, mother to mother.  Is  telling a mom about 
fenugreek or gentian violet alternative?  What if I  just offer her the websites 
to read?  Is that still sharing information  about alternative care?  What 
exactly can I tell her?  Ask her  doctor?  Why did she come see me and write a 
check if all I can say is  "please tell your doctor your nipples are pink, 
burning, fissured, and that you  have been on antibiotics in the past two weeks" 
but I cannot tell her why or if  the doctor says "yeah, so what?" and she cannot 
get any help?  When I see a  tongue tie so obvious it is hard to imagine how 
her pediatrician missed it, can  I not say anything about it?  After all, she 
did already see her  pediatrician, and he did say everything about the baby 
looked great.  Well,  the tongue doesn't look great, but to say so definitely 
contradicts her  doctor.  Now what?  
 
I don't think most of us have an issue with reporting our assessments  or 
plan of care.  I think the issue of needing 'approval' though is  huge.  If we 
can no longer disagree or contradict a doctor's plan of care,  we are doomed. 
Many have posted instances when the information they were  providing 
contradicted a doctor's orders.  However, my understanding is  nurses are held to very 
strict rules about daring to disagree with what a doctor  has said to do when it 
comes to many issues birth and breastfeeding  related.  I don't know why 
these particular issues create some separate set  of rules for obedience, but they 
seem to. No, I am not a nurse, so all is  hear-say, but, if a doctor orders 
the wrong medication a nurse better make sure  it is corrected or she is liable 
also, but if a doctor orders something related  to birth or breastfeeding a 
nurse better do it even when there is research and  evidence to the contrary.  
If she is teaching childbirth ed classes, she  better not mention any risk of 
medications during labor or heaven forbid  encourage a mom to not have an 
epidural. That is not allowed.  The status  quo must be maintained.  All moms get 
the standard of care, and  the nurse providing education best be encouraging 
it to stay as such.   Or risk reprimand.  This is actually the very reason I 
could never ever be  a nurse.  The stress of knowing they were wrong, and having 
to follow  orders anyway would give me such stress I would surely be ill 
regularly.  I  have such respect for nurses who can maintain their sanity and the 
balance of  doing what they know is right and not disobeying orders.  Eeks.   
Military and nursing, two things I could never do. Haha.
 
Here comes this new edict of Scope of Practice though that states all LC's  
must not contradict a hcp's advice...even if they are dead wrong!!  I could  
not manage to that.  I don't know what to do now.  I have to either  follow the 
Code of Ethics and protect my client, or follow the Scope of Practice  and do 
damage to my client.  Such a dilemma, and to know it  took two  years to 
provide it.  There are other things in the Scope I find very  poorly written and 
not complete.  The providing information on  medications...only as it relates to 
milk supply?  How about how it relates  to safety to the baby?  That seems 
odd that we can only tell a mom if her  milk supply will be affected, but not if 
it is contraindicated for use in  breastfeeding mothers.  
 
I think that we should indeed be modeling our Scope of Practice after those  
care providers who do not need a doctor's permission to treat.  Even though  
those are licensed providers, we can still find that balance that allows us to  
be a profession in our own right.  I am thinking many countries and even  
within the US different states have different scopes of practice for  
professions, but this is possible to do.  We need to look to a profession  that does have 
the option of collaboration with others in the health care team,  but also is 
allowed to see a client without a referral from a health care  provider.  
Massage therapist comes to mind. In my state they are licensed  and reimbursed by 
insurance companies.  
 
I think the real question is why.  What is the true goal of  IBLCE?  To make 
IBCLC a stand alone profession, or only an add on?  To  basically demote all 
IBCLCs who are not medical professionals with licenses to  practice down to the 
new credential of 'peer counselor'?  What is the  purpose and goal and then 
we know the why.  For now, I am not sure what to  do.  I honestly cannot 
practice if I cannot disagree with a doctor.   Heck, I may not even know I disagree 
until after I answer the  questions!!!!  Sheeze.  I do not understand how this 
could have  happened without even asking those of us who work in this field 
what we consider  to be appropriate for our scope of practice and to ask not 
only nurses and  doctors, but all of us.  I am sure there is a balance of 
providing  appropriate care, sharing information with mothers without a gag order, 
and  maintaining a professional credential.  I can see no purpose in paying big 
 money to be a peer counselor so am not sure why they even wasted time with 
that  idea.  All I can think of is they have a bigger plan and the peer  
credential is a piece of it, providing a scope of practice that won't let us  
practice at all unless we are nurses or doctors is a piece of it, and now I am  just 
waiting to be shown the bigger picture.
 
Best,
Pam MazzellaDiBosco, IBCLC, RLC
Professional Breastfeeding Assistant? Specialist? Consultnat?
 
 

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