While this thread fizzled about a week ago, there were a few posts to which  
I wanted to respond, but I got sidetracked by life events.  I continue to  
think that we need to think about these issues and talk about them.  This  is 
going to be a mish-mash of ideas, and for that I do apologize, but I've not  got 
the time to construct a masterpiece tonight!  I'm sure you'll  understand.  
 
At least one person wrote that she was concerned that some of the posts  
sounded like "RN bashing".  I would disagree with that statement, in fact,  I 
think you could argue the opposite.  Because it is so difficult to  accumulate 
practice hours, I think the expression of frustration with nurses  could also be 
described as "RN envy or R-envy".  Of all the people who  aspire to become 
IBCLCs, the fact is, it is easiest for those working in L&D  or postpartum units 
to accumulate the required hours, and they get paid for it  at the same time.  
For practically everyone else, getting supervised  practice hours means a lot 
of volunteering, creative employment, finding  gracious mentors, and luck.  
 
Because the IBCLC is an INTERNATIONAL credential, the level of preparation,  
the establishment of 2 or 4 year college level preparation courses, even  
required reading and./or coursework and the level of difficulty of the exam  
itself are incredibly complex issues.  Some of these issues, hopefully,  will be 
addressed by the US Lactation Consultants Association, or whatever form  that 
organization takes, if it does at all (fyi ILCA is currently considering  the 
formation of some sort of American affiliate or association to more fully  
represent the needs and desires of US based IBCLCs, while being able to focus  
ILCA's attentions more fully on the issues of non-US IBCLCs).  Pathways  which 
might work here or Canada or Australia might become additional  options.  
Mentorship pathways like Pathway F could be reinstated to offer  qualified candidates 
an opportunity to become IBCLCs without facing 5-10 years  of accumulating 
practice hours.  Even with these options, though, more  issues are raised...what 
makes a qualified mentor?  Who would help design a  university program?  
Would the program be roughly standardized as are other  allied hcp programs?  If 
so, by whom?  
 
I want to make it clear that I was not, and am not advocating that IBLCE  
determine, set the standards for, or in any design any type of college level  
program.  As Linda Smith pointed out, that would be inappropriate.   But I do 
think it is appropriate for the IBLCE to be concerned and interested in  these 
issues, and to consult with ILCA, universities and other interested  parties as 
appropriate as the profession continues to develop.  
 
Someone asked if I was advocating a 2 year program as opposed to practice  
hours.  The answer is no, at least not right now, and not for  everyone.  As 
noted above, if we in the US have not yet  been able to  launch successful 
college level programs, it can hardly be expected to see such  programs be 
established in developing countries of Africa or Asia.  I think  there has to be a 
number of eligibility pathways, at least for now, to allow for  all of those who 
want to work toward certification to be able to.  
 
The issue was raised that some people, it appears, are taking "short cuts"  
to get their practice hours.  It is true that accountability for practice  
hours is based on the honor system.  There are no time limitations on the  
accumulation of hours, and it is economically impossible for each application to  be 
individually researched.  How can one reasonably go back 15 years and  try to 
verify hours worked at a hospital now closed?  Random checks are  made on more 
recent hours.  My gut feeling is that there are  those who falsify their 
hours, and those who claim questionable hours, but  for reasons of not enough 
staff to investigate, or not enough blatant facts to  "prosecute", the benefit of 
the doubt has to be given.    
 

Whatever the issue, the exam has always been an "entry-level" exam.   
However, how do we define "entry level"?  I have heard more experienced  IBCLCs worry 
aloud that new IBCLCs don't understand or use concepts such as test  weights, 
are not up to date on the literature, or do not know the proper use and  ways 
to fit a nipple shield.  The issue then becomes, should an "entry  level" 
person necessarily know about test weights, difficult latch situations,  or 'more 
advanced' problems?   How do we define these things?   Partially by the role 
delineation studies, which are only done every 3-4 years,  and are on various 
topics.  Partly by consensus of more experienced  IBCLCs.  The profession is 
so young and developing, it's hard to say.   Different practice venues call for 
different skills.  Just about every  issue is vague,and will remain so for a 
while I think.  Barbara Wilson  Clay speaks eloquently about being in 
situations years ago when she wasn't sure  what to do.  I don't think she'd hesitate 
to tell you today if she  encountered the same situation, she would not 
hesitate to seek counsel from  colleagues, search the literature, and invent a 
technique or solution if she had  to.  We all must practice in this manner, whether 
we passed the exam 20  years ago or in 2005.
 
Another way to address these issues might be the introduction lower level  
credential.  The lower-level credential is, I personally believe, important  for 
IBLCE to implement.  I don't think it will weaken the IBCLC credential,  
rather; it would be my hope that many people who take the IBCLC exam would  choose 
this credential instead because it would have fewer requirements for  
eligibility, indicate a certain proficiency in basic breastfeeding helping  skills, 
yet not a qualification to do the specialized work of an IBCLC.  It  would set 
a clearer line between "counselor" or "helper" and "professional"  or 
"expert".   At that point, the IBCLC exam could be made more  difficult.   It  could 
be, with the proper marketing, education,  and design, a credential that would 
solve problems for IBCLCs, not make  more.  But it would be a risk.  I agree 
with Barbara Wilson Clay and  others that educational, and practice standards 
should be higher, the test more  difficult, to achieve the alleged "gold 
standard" but they have to be defined  and established in a way that is 
psychometrically valid, can withstand the legal  challenges it would face, and 
importantly, meet the requirements of the National  Organization of Certifying Agencies, 
without whose blessing, our credential  would lack a GREAT deal of clout.  It 
is a very complex issue and will take  years to work out.  
 
One of the other major issues facing our profession is money.  There  is a 
staff of 5-6 at IBLCE.  Twice the staff, dynamic leadership, and state  of the 
art computerization would provide a start to addressing some of  these issues.  
I personally believe offering the option for computer-based  testing would 
also help.  I've said it before, and I'll say it one more  time.  If you care 
about these issues, you can do two things.  Join  ILCA, and don't whine about 
exam, recertification and CERP fees, which keep  IBLCE in business.
 
The level of training, reading, background, experience knowledge, needed to  
become an IBCLC is interpreted differently by each person.  It used to  drive 
me crazy.  I've met people who completely outlined the entire Riordan  and 
Lawrence books, and other test-takers who never opened one book on the  
recommended reading list. The thing is, you can pass with the lowest pass  score or the 
highest, but after the exam, it doesn't matter.  Both  candidates are IBCLCs. 
  Until we have a standardized educational  program, at least as one pathway, 
it is going to be very difficult to make this  the quality profession you 
envision it to be.  We need to discuss this  more, and more openly.  
 
I hope more of you will join in this discussion.  
 
Barbara Ash, MA, IBCLC
 
 


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