I have been following this thread with great interest, as it has been one
of
my major concerns both in private practice, and during my past years at
IBLCE. I agree that Debbie Albert’s original post (May 16) that the issue
of
uneven skills among IBCLCs is one that we need to discuss, not only here,
but
also within our credentialing organization, and our professional
association as
well. While the profession was born and has come remarkably far in 20
years, we have a long way to go if we aspire to full recognition and
respect by
the medical community, insurance companies, and the public at large. No
one
organization or group of people can address these issues, let alone ‘solve’
them, but all of them need to acknowledge that they exist (so far undone)
and
include plans in 5 and 10 year plans to direct actions to ameliorating the
situation.
This post is by no means a comprehensive plan, nor is it meant in any way
to
be a criticism of IBLCE, ILCA, USBC or any individuals or organizations who
have worked tirelessly to build our profession to where we are today.
Indeed,
I have great admiration for all of those who have contributed to the
development of our profession. Instead, it is my solely my personal
views, offered
in good spirit, as an honest reflection of what I see as the major
challenges
facing us now and in the immediate future. They are discussed in no
particular order.
Debbie called our attention to mothers and babies coming to her care with
problems that never should have been allowed to progress to the point of
nearly
no-return. I have heard this from many colleagues. I sympathize
completely, having built private practices in Australia and in the US
dealing nearly
exclusively with ‘train wrecks’ referred by hospital IBCLCs, public
health
IBCLCs and nurses, other private practice IBCLCs, LLLLs, and others have
not
been able to help. I find it appalling that within 20 seconds of the baby
opening its mouth I can clearly discern the problem…frenulum, palate,
oroboobular disproportion, or a sucking problem that mystified 3 or 4 other
IBCLCs.
If IBCLC is the “gold standard” credential, and this happens and, it would
seem, more often than it should, then “gold” isn’t clearly enough defined.
Yes, we should be worried about what the silver and bronze standards are
(CLC,
CBE, CLE), but we also need to be concerned about the universal quality of
our professionals. Setting ourselves up as the best means that we need to
perform as the best. The IBCLC is advertised as the entry level
credential, yet
also viewed as the crème de la crème in lactation counseling; it seems to
me that this is a disconnect. Either the entry level person needs to be
able
to deal with the complicated problems without screwing up, or maybe she
shouldn’t be an IBCLC. We complain about the CLC, CBE, CBC, etc. but who
knows
how many IBCLCs are actually performing at this level? I know that some
say
that there are some doctors who are better than others, some OTs who are
better
than others, etc., but they have the luxury of having been around a while,
AND having subspecialties. We don’t and what we do has an overarching
impact
on the entire medical profession’s view of lactation consultants.
Yes, horrors, I’m saying maybe everyone who is interested in lactation,
sincerely wants to help mothers and babies, or who thinks the credential
will get
her more money, is pursuing it because it adds to the string of letters
behind her name, because she needs to keep up with the Joneses, or for
whatever
other reason doesn’t really need to be an IBCLC, and doesn’t really
deserve
to be an IBCLC. Perhaps the solution is the lower level credential, one
that
will ensure a level of competence that does not include the ability to
recognize and work with such problems as these. I think it’s more important
to
have fewer qualified IBCLCs than just to have a lot of them. As others
said
before, the incompetent, misinformed, uneducated, and/or inexperienced “
gold
standard expert” doesn’t do our profession one bit of good. On a local
level,
it hurts it. You know it only takes one or two pediatricians to spread
the
word that the local lactation consultants are not very knowledgeable. (And
in here, I would include those PPLCs who don’t report to the primary care
providers after consultations. They are not meting their professional
responsibilities either.)
Many of us have encountered IBCLCs (unfortunately, many of whom, but not
all
of course, are hospital based) whose expertise is limited to babies under 3
days of age. The “gold standard of lactation expertise”, friends, extends
beyond 3 days. Not being able to recognize a nursing strike, not knowing
how
to deal with teething, tandem nursing and a host of issues can be “book
learned” enough to pass the exam, but in reality how many candidates have
no
experience with these situations, and have little or no motivation to
acquire it?
Even if these IBCLCs don’t use this information on a daily basis, they are
in fact, not equals to other IBCLCs, even though we all pass the same exam.
These candidates can and do pass the exam based on being a post partum or
labor and delivery nurse for years, presumably some studying, and with a
one
week course to fill in the gaps, bingo, they are close enough to pass.
Even
more disconcerting is that IBCLCs in private practice have also not
developed
the skills necessary to solve more that the basic latch and sore nipple
problems. And let’s not even discuss the ever growing concern of mothers
who enter
the consultation with sore nipples and low milk supply and come out with a
pump and a decision to express milk and bottle feed the baby. Breastmilk
feeding is not the same as breastfeeding, although you’d be hard pressed to
understand the difference in some areas of the country.
Practice hours and lactation specific areas, as well as medical background
education for non-medical candidates are other areas which desperately
require
review. How can it be that some candidates pass the exam with as little as
500 practice hours, and others require 6000? Are the standards set 20
years
ago based on post-secondary education still valid? The quality of the
practice hours could well be more important than the quantity. Yet, there
is no
mechanism to monitor these hours. Financially for IBLCE, realistically,
administratively, it is impossible, unless candidates would be willing to
pay
thousands of dollars for the exam process, and they are not. Few people
realize
that our credentialing organization exists nearly exclusively on exam
income
(small additional income is derived from CERPs fees, which, however, do not
even cover the cost of administering the CERP program). It is unreasonable
to
expect to run a business (rent, utilities, insurance, salaries, office
supplies, exam development and administration expenses, board meeting
expenses,
legal and psychometric fees, etc…..) AND add individual assessment
requiring
time, travel, hospital/work environment set up time, etc. with a staff of 4
or
5?
Prospective candidates went nuts a couple of years ago when the additional
requirements for the “background in” education requirements were announced
several years ago, so much so that applications to take the exam went up
considerably, then dropped equally considerably the following year. Why?
These ‘
additional requirements’ were perceived as unrealistic and unfair burdens
that
previous candidates and nurses didn’t have to meet. And what were we
taking
about here? 8 clock hours of education in areas meant to help non-health
care professionals and those with no prior exposure to understand the
basics,
and be able to communicate on an elementary basis with other HCPs without
making fools of themselves. Clock hours, not university credits. For
anatomy
and physiology hardly enough time to even learn to identify the body’s
major
systems let alone learn anything about physiology. Yet complaints. I
remember
a woman to ask if “large animal anatomy” (she was a pre-vet major in
another
life) could be used to fill this requirement. What kind of professional,
gold-standard behavior is this? Her argument: humans are really large
animals. Answer: No. If she couldn't even bear the thought of an extra
one hour
of training before sitting the exam, what could we realistically expect
afterwards?
Concerns have been raised about falsification of hours and educational
experience in exam applicants. I have no doubt that this happens. Again,
resources force IBLCE to believe that applicants are telling the truth,
that
supervisors signing off are honest, that education providers are
guaranteeing that
students spend the entire courses with their butts in the their chairs.
Spot
checks are made, tips are followed up, suspicious applications are
investigated, and each application is completely read checked to make sure
the math is
correct, but beyond that, realistically, what can be done? (Just FYI, the
certification industry standard is that not every application is checked;
generally a random sample is taken.) Do you want the breastfeeding
police to go
out to verify each application? And do you want to pay for it? That would
involve an increase in exam and recertification fees. And even if each
application is checked, if the supervises signs an affidavit that the
hours are
correct, short of subpoenaing hospital records (unrealistic at best), one
is
forced to accept their statements, true or false. The costs involved would
be astronomical. Current exam fees do not even allow the organization to
rent
sufficient office space, pay employees average nonprofit wages, or exhibit
at conferences that would be ideal venues for recruiting. Perhaps the
large
number of hours necessary encourages fraud; role delineation studies are
meant to keep these requirements current and valid, so perhaps we will see
changes in the future.
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