Interesting time for me to un-nomail and come out of lurking (I am prepping
for a guest lecture in July on Political Lactation and I knew right where
to come <grin>).
Licensing of nurses, physicians, or any skill has never been about useful
(aka applied or actual) competency; licensing *only* indicates that passing
(an) exam certifies within a certain confidence margin (statistically-
speaking) "entry-level knowledge." Even the fields of nursing and medicine
assume that true competence (expertise) comes after duration of practice,
which is why everyone rolls their eyes & breathes deep sighs of tolerance
around "new grad nurses" and "interns" (new grad MDs). See Patricia
Brenner's (UCSF) extensive work on how (nurses) move from Novice to Expert -
it applies to this discussion.
So, let's say there were graduated exams starting with entry level LC
practice, then after 5-years of practice (Advanced beginner?), and after 10-
years of practice (almost-expert?), etc, then I suppose, yes, we should
take the exams at 5, 10, 15 years. Ludicrous, right? What would be tested
in the exam? What would be the point? I have met incompetent RNs and MDs
who did not gain competency by virtue of years on the job; some people
never "get it" and a retest won't make them "get it" either. All board
exams do, are offer the public some small measure of guarantee of entry-
level knowledge in the field...Period...not even that the person will apply
that knowledge correctly when needed. Why retest entry-level over and over?
And knowledge does not always translate into practice. I have repeatedly
seen both MDs and RNs swear they practice family-centered care and answer
pre- and post-tests correctly demonstrating that they do, yet keep the
parents from touching their NICU baby or feed formula because the EBM is
frozen down the hall or (fill in the blank). You have seen this, too. They
talk the talk, but don't walk the walk.
So let's say I were to take the same exam over and over, that says, yes,
after 5 or 10-years, - what do you know?! - I still have "entry-level"
knowledge (not competency). What exactly does that say to the consumer? In
effect, nothing more than it ever did. Keeping a license going by CEs at
least requires one to get into some education venue periodically.
The only reason I'd ever have to retake my RN boards again is
a) if I didn't accumulate enough CEs for renewal, or
b) I allow the license to lapse.
Mind you, that is "lapse" - even the BORN allows me to pay a reduced fee to
go "inactive" and when I'm ready to reactivate, all I have to do is show
proof of sufficient renewal CEs and pay the full fee. Otherwise, I pay a
small amount every two years to renew active or inactive.
ILCA should have adopted this approach years ago.
I passed my first and only IBCLE in 1988 and have practiced as a private
lactation consultant before and since passing the exam. I have ALWAYS
maintained from the beginning that the IBCLC functions as a license
regardless of how it is named and ILCA should have called it (should do)
what it is: a national License.
Way back (1993) when I inquired about the logic of mandatory retesting
instead of regular renewal by CEs, because it seemed that the certification
was functioning like a license, I was told that ILCA did not want to issue
licenses because then IBCLCs "might get sued if they have a license."
Listen folks, any good (and even a bad) lawyer will sue anyone within
spitting distance if it looks remotely possible that the person had
anything to do with the complaint, licensed or not
So I personally chose to boycott getting my IBCLC renewed and have
maintained my one-woman boycott against the cost of retesting every 5 years
by not taking the exam again (not that anyone has noticed or even cares)
and so no longer claim the IBCLC letters (I have enough letters anyway).
(For a time, I put "IBCLC (1988-expired)" after my name but the ILCA
lawyers sent me a cease-and-desist letter. It was not a hill I wanted to
climb, let alone die one.)
The moms I work with don't ask me if I'm credentialed, but have I ever
worked with a baby like theirs, and can I help her without making things
worse? Not being IBCLC has never hampered my practice; not having
experience surely would have.
These days, I am an unlisted LC because my focus is on another aspect of
newborns within the field of maternal-child nursing. Nevertheless, I still
get consultation calls. In the 6 months, I consulted with three different
moms to undo the damage and terrible advice given by current IBCLCs
including one well-known nationally BF-lecturing IBCLC MD. All three
situations were Lactation 101 kinds of "problems" that were completely
iatrogenic in origin. One mom had consulted with 2 different lactation
clinics, including the MD-that-shall-remain-nameless, before calling me.
She had been given erroneous information about the cause of her problem,
advised to use an SNS, told to consult a neurologist, and then at the 2nd
clinic, 4 IBCLC RNs stood around her (one had gone to get another and then
another and then the 4th, but not one could figure out the problem) shaking
their heads sadly while apologizing and said "Well, there's always formula
if our suggestions don't work." (What kind of advice is that on their first
consult visit?!?!) I was able to correctly diagnose her problem *over the
phone* without seeing her or her baby (she lived on the East Coast) purely
by listening carefully to her description of the problem (she had a raging
case of thrush on her nipples) and provide telephone encouragement over the
next two weeks that saved her BFing. If you are an expert, you don't forget
what you know. Babies and BFing are not that complex, but you HAVE to know
how the system works!!
Frankly, the *basic* scope of practice for nursing (RN, LPN/LVN) and
medicine allows/includes lactation consulting whether or not one has taken
extra coursework. Even your orthopedic surgeon is technically and yes,
legally, protected by the MD license/scope of practice to provide lactation
assistance (not that s/he would, but it is technically allowed). (However,
one's malpractice insurance company may prefer evidence of LC training if a
lawsuit ever came about from an orthopod providing lactation consulting.)
Therefore, creating a(nother) license to distinguish an LC should logically
be for the non-licensed-healthcare professional (to bring them on par with
what is already allowed in the scope of practice for the licensed
healthcare professional for this specific field). The IBCLC for the already-
licensed professional simply demonstrates "entry-level knowledge."
Come to think of it, I can wash my patient's hair without a cosmetology
license, but I sure as tootin' want my hairdresser to know how to clean
those brushes and curlers and maintain a germ-free lice-free salon; I want
some minimal guarantee that at least once upon a time s/he knew what to do.
(Someone mentioned manicurists in this thread - even with licensing, there
is a pandemic of nail fungal disease in this country, and where do you
suppose that comes from? I once got a nail infection from the cuticle
scissors that was so awful, I was on expensive antibiotics and I could not
work in L&D - did not dare to work - for 2 weeks until it stopped draining
and healed. I have never gone back to a nail salon since then, so doubtful
am I that it will be clean.) But I digress.
The issue about reimbursement isn't about being licensed or not and won't
be solved by licensure, though it may help slightly. I got reimbursed by
insurance back in the 80s and, as a Blue Cross case manager back then, I
approved reimbursement for LCs and pumps to non-licensed pump depots. I
even published 3 articles in Medela RoundUp on reimbursement. (Part of the
problems of claims denials have to do with inaccurate claims submission,
but that's another thread altogether.)
Until we as a group, and more importantly the *consumer* - as a group -
like the nurse-in moms in NYC - start to complain loud and long to
*insurance companies* (and all 3rd-party payers) about the need for
reimbursable lactation services, payers won't care one whit about whether
or not we have a license from ILCA or some state agency. They're the ones
that call the shots in that regard and they are not about to spend more
money when they currently don't do so. (And since they won't reimburse for
formula in case of BFing failure, they unfortunately don't see paying for
BFing as a cost-savings treatment in lieu of something more expensive -
formula - that ultimately introduces greater costs for them in the long-run
for things like asthma, obesity, diabetes, etc. Strange world, but there it
is.)
Some of the above is dictated by the society's values. Scandinavia has a
different perspective than the USA, as does China presently.
So why doesn't ILCA move toward national credentialing with a standard
pattern of renewal (NOT retesting unless the IBCLC lapses)? This would
allow the states to easily recognize entry-level knowledge for the non-
licensed person. Nursing has used one single national board for years and
the states all accept the same test. This also makes for easy reciprocity
when nurses move from one state to another. Another example is for
specialty and advanced practice nurses (APNs) (NPs and CNSs) - the American
Nurses Credentialing Center provides national exams for certain
subspecialties that are then recognized locally:
http://www.nursingworld.org/ancc/certification/cert/eligreqs.html
One last thought: IMHO, the IBCLC should *never* become a barrier (e.g. an
exclusive tool) to this body of knowledge for access by mothers. Most of
the world's moms need someone to help them get started on BFing, yet very
few of the world's moms have access to adequate prenatal care with even a
lay midwife, let alone a licensed or credentialed lactation expert
postpartum. Better it would be for us few lactation experts to train lots
of lactation "doulas" to help the world's mothers and then we work with the
truly difficult cases - a trickle-down effect as it were - or BFing triage.
I will be interested to watch how this evolves. I may even become IBCLC
again.
Thinking of what's breast for moms & babies,
Katharine West, MPH, MSN, RN, CNS
Loma Linda, CA
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