I honestly don't mean to sound critical, because I served for many, many
years as a LLLL who ONLY did ph. counseling, and I know that I was helpful
in that capacity.  However, there are some situations where there is risk to
the baby to be involved in long discussions with a mother who isn't "ready
to be seen" in person by someone who can make a realistic assessment about
her breastfeeding situation.  In a way, it enables the mother to remain in
denial.  It also prevents the LC from giving the MD any empirical
information about the feeding situation to help him/her make a decision.
Our role is also to educate, and this includes MDs who may lack info on the
increased risk of lactation failure experienced by women who have hx of
previous  breast surgery.  If the MD doesn't even know the woman has had a
reduction (common in my experience) someone has to tell him/her. If you see
the woman in person, you at least get a signed consent which assists you in
communicating with the doctor.  The LC can still ph. the MD with her
concerns, but lines are less clear when the LC's relationship is just phone
chatting with no observation.

 My policy is to be friendly and spend a few min. helping mothers on the ph.
sort out what kind of problem they have.  If it is something (ie
information) that can be competantly handled that way, I will do a ph.
consult.  But I have limits which I state up-front about situations where I
consider ph. consults to be less useful or positively risky. If the woman
doesn't want to see me, I refer her on to someone else, but I won't continue
to have a phone-only relationship.

 A situation where mom has had invasive breast surgery, baby is losing a lot
of weight, and mother has been evasive with care providers fits into this
category. As much as I would love my doctor to dx and treat me over the ph.
(so I wouldn't have to come in or pay) I respect them when they remind me
that their ethics demand that they see the condition and the patient in
person, in order to provide the best care.  They seldom waffle on this
point, and I don't get furious and hate them over this issue, because I am
used to and expect this response.  If LCs are to be professional, we do have
to have some boundries and protocols, because when situations like this go
sour, and we are involved, the bad press is harmful to us all.  And the
bottom line is we are ethically bound to protect the baby.

Barbara

Barbara Wilson-Clay, BS, IBCLC
Private Practice, Austin, Texas
Owner, Lactnews On-Line Conference Page
http://moontower.com/bwc/lactnews.html