Dear all:

I too was very impressed with Deborah Wetherell's important observations about the conditions under which RNs must work.  In New York City, the ability to care for women in the postpartum period is being compromised by the economic problems of our health care system.  When I started my private practice a little over seven years ago, I witnessed the closing of the only freestanding birthing center in New York City.  Since then we have had more closings, including an entire hospital -- St Vincent's.  Within these hospitals I know there are many caring individuals who would like to do a better job, but the constraints become too large to overcome as an individual. Part of the problem is the lack of regulation of an insurance industry that focuses on fees for service rather than outcome.  

I know Judy Fram has posted about the consequences of insurance coverage for practitioners before, but I still had my moment of jaw dropping incomprehension when I went for physical therapy.  We spend $20,000 per year for insurance because both my husband and I are self employed.  Every year our insurance goes up from 10-20% and so we cut back on our coverage to be able to cope.  Our insurance CLAIMS that they cover 30 visits for physical therapy.  I pay a $30 copay fee.  For the first 10 visits they covered, not 75% of the true cost, not $50 of the true cost, not 25% of the true cost --- they covered $4.  Now they pay -$3.  Yes, dear ladies and gentlemen -- NEGATIVE $3.  This is for 30 minutes with a doctor of physical therapy, and another hour and a half of exercise.  This is a money losing proposition for the physical therapist and I do not see how the insurance industry can get away with claiming this is coverage.  This is a tiny little problem for my husband and I, but a large problem for the country as a whole when you multiply this by bigger health problems and people who have worse coverage than my husband and I.  

Now, I have already posted on this topic before, but I will repeat this again.  I had a good reminder when the New York Lactation Consultant Association Theater Group did a series of skits on ethics.  We have the good fortune to have lactation consultants in New York who are professional actors.  Their character development was fabulous and they stimulated an animated discussion whereby my dear colleagues really hashed out a lot of ethical issues with real world examples.  The one that was most striking is one very gentle thoughtful IBCLC who is always a good listener discussing how she found her feelings changing now that she is working part-time in a hospital.  That the time pressure made her feel the need to just grab the baby and get the baby to attach or tell the mother just do it.  She voiced what Deborah Wetherall so articulately discussed. And her admission of this feeling that others have felt, made it possible to discuss and problem solve.

Lest you give up on those who you THINK are not motivated,  I have posted before on the major transformation that occurred in Maradi, Niger among demoralized health care workers.  They live in an area of the world that is dry and dusty had prone to famines and rarely get paid.  In 1985, the Peace Corps Volunteers and the nongovernmental organizations had written these workers off as useless.  Years later I was blessed with attending a conference that these workers developed -- where they presented their own data collection and problem solving.  These workers were motivated by a project that enabled them to take charge of gathering their own information and acting on it. 

So, I think we do need to look at the bigger picture and consider that empowerment of others can often make a huge difference in their attitudes.

Best, Susan Burger, MHS, PhD, IBCLC

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