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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