Funny this should come up on Lactnet!  This was just the topic of
discussion with another IBCLC who is trying to make those boundaries
for her new office.  I'll have to make sure she knows to check Lactnet
this week.

This particular situation could also be called follow up boundaries. I
charge enough to cover that follow up that lasts a while. This is not
really about free phone help with no consent forms filled out, because
this client already did pay for a consult.  This is more about when
does follow up become another consult. I think that is something you
need to cover up front when you first set your fee.  I tell mothers my
fee for initial consult and for follow up consults...that way they
assume there may be further need for another visit up front.  It is
also in my consent form that follow ups may be necessary, etc.  I know
when I am charging that fee she may be calling me for quite some time,
and I expect that. I think this is one area everyone has to decide for
themselves and be upfront about it with the initial consult.  Making
boundaries up front is more than fair, but providing them after the
fact may cause hurt feelings.  I tell moms up front they can call me
as often as they need to until it is resolved, and I will come back
for xyz fee for a follow up visit if they need me to.  So, if I were
also going to charge for phone follow up, I would state that up front
to, and put it in my consent form so it is clear and up front.

In general, if it is a first time call, and it is something I can
answer on the phone, I do. And, if I can send her to find the answer
herself, I do.  I do not tell every mother's doctor I spoke to one of
his/her patients.  I don't even want to imagine the time it would
consume if I sent a report for how long you can store milk, how much
milk to leave behind when you return to work, how often a baby wants
to breastfeed is normal, etc.  I report when what I am doing is
related to what a doctor may care about.  I doubt they give two cents
about milk storage and don't need the extra paper in the file. On the
other hand, I want to be sure it is there if I am worried about weight
gain or infection, etc. Not every issue discussed with a mother
requires we contact her health care providers.  That is indeed within
my interpretation of the IBLCE code of ethics as it stands now on the
website: "Tenet #23. Require and obtain consent to share clinical
concerns and information with the physician or other primary health
care provider before initiating a consultation."  Nowhere does it say
'written" and it says "clinical concerns".  Not to mention it does not
define consultation. Somehow I don't think every question a mother
asks me falls under 'clinical' concerns nor do I consider every phone
call a consultation.   So, this is well within ethical behavior.  To
me, it would be more unethical to go see her, charge her a fee, and
then she doesn't really need to be seen. Personally, I can't afford to
just go see every mom who calls me and determine it should be at no
charge when I get there.  Of course, that may change some day too.
Maybe some day I will hold little workshops just for these things and
charge all attendees a small fee.  Who knows what I may do and what
boundaries I may need to create in the future.  So, if you started out
thinking something worked, but now it doesn't of course you should
change that and make your work stay what you want it to be.  Just tell
the moms and assume they will understand this is what we do for a
living as well as for passion.

I think this is a no right answer issue for some of us.  If I saw
every mother that phoned me, I would need lots of hours in my day that
do not exist. And many moms would not get an answer. The possibility
exists that we lose more than we gain when we nickle and dime our
clients so much in private practice that they no longer bother to call
at all...you know...don't call 'those' people because they only want
your money.  I have had plenty of my clients tell me that they could
not get the LC they saw to call them back or answer their questions
without paying more money.  I think it would have been more
appropriate to share that reality with them upfront so the moms were
not frustrated by not being able to have some follow up. Some private
practice LCs will feel much better only charging for all lactation
related conversations, emails, etc.  That is totally fine too and what
works in some areas may not work in others.  The USA is odd that way.
From one county to the next in my state fees vary quite a bit because
of what the market will tolerate.  The real lucky ones are the ones on
a salary who don't have to struggle with this at all!  I miss my
salaried days for this reason only.  No stress over fee for service
issues.

For now, I offer websites, send an email or two with some basic
information.  I include my fee schedule for consults with the email.
I have boundaries for when I will never give information on the phone
or via email.  For me, that is weight gain issues of any kind and sore
nipples that providing a website on latching can't fix with one or two
feedings.  For me, that translates into more business, not less.  When
I help one mom by just giving her a link to go to or share information
easily accessed if she knew where to look, she remembers me to her
friends and family.  I have received so many referrals from women I
never even met...both from their doctors who appreciate that they
received the information and direct friends and family. It is not good
business in my world to say "I'll only answer you for a fee" and I
can't change my world. I completely respect those who do otherwise
because they can and the market expects it and profits from it.  If I
refused to answer without seeing them, they would likely hang up, but
not pay to see me.  That is just the reality of situation.  And,
realistically, like I said, I only have so many working hours a day
and you just physically can only get to so many homes a day.  I enjoy
the support aspect of the work too, so I don't mind the moms calling
me to just be sure they are on the right track, etc.  Yes, I send them
to LLL local meetings, too.  But, if I don't feel the need for the
boundaries, that is a personal call.  Again, back to we all have to
make boundaries that are unique to our own situations and there is no
one right way to do this.

I think any boundaries you feel are necessary are the ones you should
make. Some work set hours, some are available all the time, some work
in an office only, some work from home, some work in a hospital and
are only working when on shift, etc. etc.  We all come from very
different backgrounds and work in very different settings.  I don't
know that we can apply what works for one to work for another.  My
boundaries may be what they are for now, and may change in the future
when they no longer work for me.

Take care,
Pam MazzellaDiBosco, IBCLC, RLC

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