We are a group of 8 IBCLCs, covering a moderate sized community
hospital for part of the day, 7 days a week.  We have come a long way
in our acceptance over the last year.  Now a problem has come up that
threatens our ethics Vs our programs viability.

We (after much work) convinced our pharmacy to put L_n___oh on our
formulary and remove all other breast/nipple cream products except for
the cream one physician insisted we keep.  This a a vit E cream,
clearly labeled - "not for ingestion" with multiple ingrediants,
clearly a cosmetic product.   This physician has periodically insisted
our use of expressed breastmilk and/or L_n___oh is the cause of the
"increased rate of mastitis and/or cracked nipples" he sees since our
program started about a year ago.  He declined offers to review his
charts, we stepped up efforts to educate mothers on handwashing in case
there were any truth in this "increase" due to hand contaimination.
(Mothers were already being instructed to wash hands, we just pushed it
more.)

Over the year he has continued to prescribe the "E" stuff and we have
often times also given the mother the "L" stuff, if needed, inserting
information on what the literature states.  We could do this because
"L" is available as a "Nurse Action Request" requiring no MD order and
we are all RNs.

Now Doctor is irritated to the point of threatening to refuse to let
any of his patients be seen by our LCs if we continue to provide the
"L" stuff or to educate his patients on it's availability over the
counter.

We are concerned because he represents our largest HMO and this could
lead to a cascade of LC refusal, truly compromising our ability to see
their clients, maybe even spreading to other physician groups.

We are obviously concerned with the mistreatment these patients are
recieving.

Tactics include:
 educating our head neonatologist on the potential harm to premature
infants and having him then approach the other doc.
 approaching other docs in his HMO with literature and asking that they
then approach him.
 gathering the research specific to Vit E and making another
presentation through our nurse manager to "E"Man himself (generally
conceded to be hopeless).
 As a last resort we might approach the pharmacy and ask that this "non
edible" product be replaced in our formulary with unit dose syringes of
an edible Vit E oil.  I don't want to use it at all but at least it
would be an improvement.

QUESTIONS:
1) Any outstanding, recent references?  We have the standard textbooks,
JHL and/or literature aimed at nurses would probably be dismissed out
of hand.  We need something from the OB literature.
2) Any thoughts about the unit dose of edible vit e idea?
3) Any other strategies come to mind?

THANKS IN ADVANCE,
Carla D'Anna (for the whole of our LC program) - just north of
Washington, DC