Barbara, Jennifer and others,
I agree with much that you have to say about the field of lactation consulting.  But a few points:
1, With the baby with the broken clavicle--where was the doctor's role in all of this?  The pedi is responsible for a complete physical on  admission--soon after birth--and at discharge--a few days later. S/He should have picked it up. I am well aware that there are some pedis who do both exams at once--that's for another discussion.
2. A hospital-based LC is not required to do a physical exam other that what is necessary for her role.  I might pick up a broken clavicle, but I am a NICU nurse and I am more aware of the baby than others might be.  A hospital-based LC usually doesn't have the luxury of doing more than is required of her role, due to cuts in staffing and budget.  In private practice, you can take the time you need to do whatever you see fit.  You are one to one.  FYI, I am not paid past my shift and I am no longer giving free work to a corporation that has cost containment as its bottom line.  I have done both types of LC work and I find that they are not one bit like each other.  
3. Some of the "train wrecks" that you are seeing are the ones that we (the LCs in the hospital) will hope will recover with the time that the insurance companies will not give to the mothers to stay in the hospital where they can have someone work with them.  Many mothers are taking the epidurals and meds, despite what they may be told, that we suspect give them trouble with breastfeeding.  It may be that someone who teaches in a childbirth program may not be allowed to say that, i.e., as I am not allowed to recommend herbal preparations at my hospital.  (There is a policy explicitly outlining this.)  Then the nurses and hospital-based LCs have 48 hours to fix the problem.  I know that I have a pretty select list of who I refer to based on the feedback I have gotten over the years.  I ask the mothers to see their pedi within 48 hours for at least a weight check.  I tell (not ask) mothers to contact someone about breastfeeding if things haven't gotten better within a day or two of going home, with information about community LCs, LLL, WIC or whatever.  Then, it's up to them to follow through.  That's where the problem is--the mothers don't always call the numbers I give them.  We're talking about a problem with self-esteem, lack of support, lack of financial resources, etc.  "Train wrecks" can occur when mothers wait too long to seek help.  The LC is her "last hope."  It should not be so.  That's why I TELL them to get seen.  Like I TELL them to see the pedi.  Same thing.
4. I have been encouraging the nurses in th NICU (about 200 of them) to become certified.  There are 9 who are presently certified, and I have just sent out an email to offer a review course for the nurses.  I got a good response--about 25.  I would be thrilled if they would become certified, even if they never work in this role.  Many of them do not want to--they think I work much harder than they do and am exposed to more hospital politics and nonsense than they are, and, besides, they get to do breastfeeding care in their role.  Why would I be thrilled for them to become certified?  Because I have seen that most of the NICU nurses who have become certified have held THEMSELVES up to  greater level of competence in lactation and breastfeeding and ask lots of questions.  The other nurses use them as a resource when I am not available and the IBCLCs will come to me when they don't know.  I have copies of Riordan and Hale available in every care area for resources as well.  They are getting worn, which tells me that they are used.  We have made it a priority to make pumping and breastfeeding the standard of care in our NICU.  It's not nirvana, but it's better than it used to be.  Change takes time.
By the way, our hospital pays for the exam, up to $500 for CEUs and a $500 bonus is given to nurses who are certified in an area relevant to their work.  
5. I know of at least one LC program where the experienced LCs moved on (due to a lack of support from administration) and the role was taken on by two brand-new IBCLCs who had great intentions, but were in way over their heads, until they actively sought out further education and mentoring.  How many hospital programs are like this?  
6. Believe me, I know it's frustrating to take on "train wrecks."  I was referred recently (through my private practice) to help a mom with a Down's Syndrome baby with a weak suck born at 36 weeks.  She had seen the hospital LC, who couldn't help her.  Mom was pumping and bottle feeding.  She then saw another LC who did a pre and post weight, and told her she didn't know what else to do but fix positioning, thanks for your check, no, she doesn't do followup over the telephone.  She then got my name.  When she called, I put her on fenugreek because she was pumping exactly what the baby was drinking from a bottle.  Two days later (after she had a fabulous response to the herb), I did an initial visit, did an assessment, deepened latch, had her check diapers, called every day until 5 days later.  I taught her to use a shield, because she had gone back to pumping and bottling, because the baby never stopped nursing 24/7.  That wasn't working for her, as she has aslo a four year old.  I have called her a few times and left messages to call me back.  I finally talked to her today and she is exclusively breastfeeding without the shield.  She thanked me profusely.  I will call her again in two days when she goes to the pedi for the weight check.  This probably was mostly due to his being 36 weeks, as he is now about 41 weeks.  But for LCs to not be aware of what to do for a baby who is a near-term, this shows a real lack of continuing education on their part.  This woman should not have been in this bad shape.  
7. As far as the continuing ed piece, I go to anything I can on premies and the science of lactation.  That's where I work.  I feel like I can latch a baby to a wall if I need to.  The skill comes in teaching the mothers to do that as well as I can.  Sometimes that comes with time and experience, as well as good supports on the outside.
8. We can only do so much with mothers in the hospital, as you have said, between phones, visitors, etc.  Also, mothers need to be at a place where they can "take in."  Most of them aren't there in the limited time they are inpatient.  So, I can talk until I am blue in the face, but if they can't listen, it does absolutely no good.  I give a lot of written information, and tell them, if you can't remember what I said, read this.  And call this number for follow up.  If there is no support to do so, breastfeeding may fail, unless the mother is super-motivated.  By the time the mother thinks that there is a problem, it can be a huge problem!
It still all comes down to support, resources, motivation, and money.
Thanks for listening.
Maureen Allen RN, BSN, IBCLC
Boston, MA--at the hospital
Groton, MA--in private practice