Re: 2 questions for those in private practice

[Guest guest]

Hi, Lyla. The IBLCE has a question and answer in their Ethics FAQ section related to fenugreek (and domperidone & reglan)--which seems to me to apply to other herbal producst intended to increase low milk supply, treat thrush, etc. You can read it here: http://www.iblce.org/FAQ%20ethics.htm. The next question in the Ethics FAQ section applies to over-the-counter fungal treatments--and the ethics behind the answer basically seem the same. You could also contact the IBLCE and clarify the ethics with great certainty.

Hoping something here helps,

-- Good Mojab, MS clinical psychology, IBCLC, RLC, CATSM LifeCircle Counseling and Consulting, LLC Website: www.lifecirclecc.com Phone: Email: admin@... Ammawell Website: http://home.comcast.net/~ammawell Announcement only email list: ammawell-subscribe

-------------- Original message --------------

greetings,

i need some input!

i am part of a group of 7 women who are opening a wellness center/day spa focused on pregnant and parenting familes. i am also on of the 5 ibclcs in a cooperative practice that currently does home visits, but will also be housed within the wellness center when it opens. 2 questions have come up:

1) we are being told that in addition to having indivdual liability insurance (which we (the ibclcs) all do, that the pracice must have generall liability insurance to cover the square footage portion that we will occupy of the wellness center (in addition to the wellness center having liability insurance.) do any of you with similar set ups have such a policy, and if so, from where, how much, any insights, etc.?

2) what is our ethical and legal liability in terms of carrying herbs and remedies for various lactation ailments - gentian violet, lecithin, herbal galactagogues, grapefruit seed extract, fenugreek, etc. i know many ibclcs do carry such products, and others do not. any guidance there?

thanks!

Lyla

[Guest guest]

1. marsh affinity insurance company offers malpractice and also general

liability insurance.

2. our clinic sells gential violet, fenugreek and more. we issue a

description handout with sale of any product with a disclainer in bold print on

top

that tells them we can not prescribe... and check with their medical provider

before use... etc

pat shelly, www.breastfeedingcenter.org.

[Guest guest]

thanks, cynthia - it is helpful to read those, but i am specifically asking about *selling* the products, not just "suggesting" them. i know ibclcs who do this as a convenience for their clients (not even as money makers) i am just curious how that fits with the code of ethics. any thoughts on that?

-----Original Message-----From: [mailto: ] On Behalf Of cgoodmojab@...Sent: Thursday, May 18, 2006 1:00 PMTo: Subject: Re: 2 questions for those in private practice

Hi, Lyla. The IBLCE has a question and answer in their Ethics FAQ section related to fenugreek (and domperidone & reglan)--which seems to me to apply to other herbal producst intended to increase low milk supply, treat thrush, etc. You can read it here: http://www.iblce.org/FAQ%20ethics.htm. The next question in the Ethics FAQ section applies to over-the-counter fungal treatments--and the ethics behind the answer basically seem the same. You could also contact the IBLCE and clarify the ethics with great certainty.

Hoping something here helps,

-- Good Mojab, MS clinical psychology, IBCLC, RLC, CATSM LifeCircle Counseling and Consulting, LLC Website: www.lifecirclecc.com Phone: Email: admin@... Ammawell Website: http://home.comcast.net/~ammawell Announcement only email list: ammawell-subscribe

-------------- Original message --------------

greetings,

i need some input!

i am part of a group of 7 women who are opening a wellness center/day spa focused on pregnant and parenting familes. i am also on of the 5 ibclcs in a cooperative practice that currently does home visits, but will also be housed within the wellness center when it opens. 2 questions have come up:

1) we are being told that in addition to having indivdual liability insurance (which we (the ibclcs) all do, that the pracice must have generall liability insurance to cover the square footage portion that we will occupy of the wellness center (in addition to the wellness center having liability insurance.) do any of you with similar set ups have such a policy, and if so, from where, how much, any insights, etc.?

2) what is our ethical and legal liability in terms of carrying herbs and remedies for various lactation ailments - gentian violet, lecithin, herbal galactagogues, grapefruit seed extract, fenugreek, etc. i know many ibclcs do carry such products, and others do not. any guidance there?

thanks!

Lyla

[Guest guest]

Re: 2 questions for those in private practice

1. marsh affinity insurance company offers malpractice and also general

liability insurance.

For a physical space? I have my indiviual liability insurance through

them, but I am talking about a slip and fall type issue, or not sure

what else, related to the physical space, that might come about in

relation to the general wellness center. We are being told that if we

rent space there, and our products are sold through the boutique, etc.,

that we also need that type of coverage . ..

2. our clinic sells gential violet, fenugreek and more. we issue a

description handout with sale of any product with a disclainer in bold

print on top

that tells them we can not prescribe... and check with their medical

provider

before use... Etc

Hmmm. Interesting. Thank you!

pat shelly, www.breastfeedingcenter.org.

[Guest guest]

I can certainly understand the desire to make it easy for mothers to find solutions. Pat's approach seems to make it very clear that IBCLCs cannot recommend a product, refers mothers to their physicians, and still makes the product easily accessible. One protection for the IBCLC might be a document that must be signed by a mother stating that she has been referred to her physician and that the IBCLC has not recommended the product, but has simply provided information about it and made the product accessible. That way if there were any legal/ethical question down the road, the IBCLC would have evidence that she was not practicing medicine.

Still, I'd love to see an official comment from the IBLCE on this--why not submit a question to them?

-- Good Mojab, MS clinical psychology, IBCLC, RLC, CATSM LifeCircle Counseling and Consulting, LLC Website: www.lifecirclecc.com Phone: Email: admin@... Ammawell Website: http://home.comcast.net/~ammawell Announcement only email list: ammawell-subscribe

-------------- Original message --------------

thanks, cynthia - it is helpful to read those, but i am specifically asking about *selling* the products, not just "suggesting" them. i know ibclcs who do this as a convenience for their clients (not even as money makers) i am just curious how that fits with the code of ethics. any thoughts on that?

-----Original Message-----From: [mailto: ] On Behalf Of cgoodmojab@...Sent: Thursday, May 18, 2006 1:00 PMTo: Subject: Re: 2 questions for those in private practice

Hi, Lyla. The IBLCE has a question and answer in their Ethics FAQ section related to fenugreek (and domperidone & reglan)--which seems to me to apply to other herbal producst intended to increase low milk supply, treat thrush, etc. You can read it here: http://www.iblce.org/FAQ%20ethics.htm. The next question in the Ethics FAQ section applies to over-the-counter fungal treatments--and the ethics behind the answer basically seem the same. You could also contact the IBLCE and clarify the ethics with great certainty.

Hoping something here helps,

-- Good Mojab, MS clinical psychology, IBCLC, RLC, CATSM LifeCircle Counseling and Consulting, LLC Website: www.lifecirclecc.com Phone: Email: admin@... Ammawell Website: http://home.comcast.net/~ammawell Announcement only email list: ammawell-subscribe

-------------- Original message --------------

greetings,

i need some input!

i am part of a group of 7 women who are opening a wellness center/day spa focused on pregnant and parenting familes. i am also on of the 5 ibclcs in a cooperative practice that currently does home visits, but will also be housed within the wellness center when it opens. 2 questions have come up:

1) we are being told that in addition to having indivdual liability insurance (which we (the ibclcs) all do, that the pracice must have generall liability insurance to cover the square footage portion that we will occupy of the wellness center (in addition to the wellness center having liability insurance.) do any of you with similar set ups have such a policy, and if so, from where, how much, any insights, etc.?

2) what is our ethical and legal liability in terms of carrying herbs and remedies for various lactation ailments - gentian violet, lecithin, herbal galactagogues, grapefruit seed extract, fenugreek, etc. i know many ibclcs do carry such products, and others do not. any guidance there?

thanks!

Lyla

[Guest guest]

Lyla,

State Farm provided me with the general liability insurance coverage for my freestanding office, at a pretty reasonable rate.

I carried fenugreek, blessed thistle, sage, gentian violet, and rescue remedy. However, they were not for sale without a full consultation, and clients were instructed to check with their health care provider prior to use of any alternative therapies. Clients were also screened for allergies, diabetes, hypoglycemia, etc. prior to discussing herbs.

Kathy Parkes, RN, IBCLC, RLC

The Lactation Connection (TLC) Inc.

[Guest guest]

ibclcs who do this as a convenience for their clients (not even as money makers) i am just curious how that fits with the code of ethics. any thoughts on that?

Selling herbs or anti-fungals is no different to selling any other medication. As IBCLC does not give us prescriptive ability, we are not legally protected for this act. It could be construed as practicing medicine without a license.

warmly,

Nikki Lee RN, MS, Mother of 2, IBCLC, RLC, CCEcraniosacral therapy practitionerFaculty, Lactation Division Maternal-Infant Program, Union InstituteFilm Reviews Editor, JHLwww.breastfeedingalwaysbest.com

[Guest guest]

ok, but the corner store sells medications, herbs and antifungals - does that give *them* prescriptive ability?

Thanks for this discussion.

A layperson is free to buy and use whatever they choose.

The difference comes when a person comes to a LC, a healthcare professional, for assistance. By virtue of training and education, healthcare professionals are supposed to know the limits of their scope of practice.

As a nurse or a LC, I have no prescriptive authority. I can refer to a certified herbalist or to a homeopath or to a chiropractor, I can suggest that there are other ways to deal with a situation. But I can't sell products or distribute them, or prescribe them.

I think the IBLCE link that sent tells the same story.

warmly,

Nikki Lee RN, MS, Mother of 2, IBCLC, RLC, CCEcraniosacral therapy practitionerFaculty, Lactation Division Maternal-Infant Program, Union InstituteFilm Reviews Editor, JHLwww.breastfeedingalwaysbest.com

[Guest guest]

Regarding "prescriptive" authority....where do you draw the line?

Herbs are dietary supplements. Would you (general question to folks here) suggest to someone that they eat oatmeal to increase milk supply? Use cabbage to decrease edema? Eat watermelon or cucumbers to decrease generalized edema? (These are all dietary suggestions -- as are herbs). Suggest ibuprophen rather than tylenol for the inflammation of mastitis?

The nurse practice act for Illinois states that an RN may not do anything that ONLY a physician may do.

In our state pharmacy techs (not licensed, not certified) are expected to recommend (not prescribe) certain OTC medications for certain ailments if asked. For example, explaining the difference between an expectorant and a cough suppressant. That is certainly something I can do in this state as an RN.

When I recommend that a mom eat watermelon or use cabbage or heat/cold on her breasts, or take More Milk Plus or fenugreek -- I am functioning within my state practice act as an RN. I am not prescribing. I am recommending. I am not writing a prescription that a pharmacist must fill from behind the counter. I also might recommend that she use gentian violet for her yeasty nipples, or monostat cream or take probiotics....

All over the counter -- all within my rights as an RN.

I do not sell any of these because our Whole Foods carries everything but gentian violet which can be gotten in any pharmacy in this area.

(\__/)(='.'=)(")_(") JanLactation Education Consultants My Mother of the Bride Blog Torrey's Blog

[Guest guest]

Would you (general question to folks here) suggest to someone that they eat oatmeal to increase milk supply? Use cabbage to decrease edema? Eat watermelon or cucumbers to decrease generalized edema? (These are all dietary suggestions -- as are herbs).

None of these are evidence-based practice. The Cochrane data base does not support the use of cabbage, and none of the other foods are even studies.

Yet some mothers have found them to be helpful. For me the key is on-going assessment. If I suggest to a mother that other mothers have tried this food and found it helpful, then I am obligated to stay in touch with her and see what her particular reaction is to my suggestion.

The challenge here for us, to bring in another discussion stimulator, is how we look in the professional arena when we suggest non-evidenced based measures to our clients?

warmly,

Nikki Lee RN, MS, Mother of 2, IBCLC, RLC, CCEcraniosacral therapy practitionerFaculty, Lactation Division Maternal-Infant Program, Union InstituteFilm Reviews Editor, JHLwww.breastfeedingalwaysbest.com

[Guest guest]

The challenge here for us, to bring in another discussion stimulator, is how we look in the professional arena when we suggest non-evidenced based measures to our clients?

************************************

Such as CST?

(\__/)(='.'=)(")_(") JanLactation Education Consultants My Mother of the Bride Blog Torrey's Blog

[Guest guest]

The Cochrane data base does not support the use of cabbage, and none of the other foods are even studies.

*****************************************

All the Cochrane data base does is demonstrate that the use of cabbage on the engorged breast for 20 minutes 4 times a day doesn't work.

I would concur with that opinion, and that is not how I use it.

Quite frankly, in nursing and in medicine we use non-evidence based practices all the time. If I did ONLY EBP, it would certainly limit my ability to help women who are trying to overcome the (often) non-EB birthing practices that have been forced on them.

We simply don't have enough studies -- we need hundreds more on the more practical aspects of lactation management so that we can practice with GOOD evidence behind us.

(\__/)(='.'=)(")_(") JanLactation Education Consultants My Mother of the Bride Blog Torrey's Blog

[Guest guest]

The challenge here for us, to bring in another discussion stimulator, is how we look in the professional arena when we suggest non-evidenced based measures to our clients?

************************************

Such as CST?

Absolutely!

One of the ways to figure out ethical decisions is to look at harm versus beneficience. Are babies hurt by CST? Are mothers? Is breastfeeding?

That can help in such decision making.

Whereas if a LC suggestions something and the mother continues to have burning nipple pain, (as in a case study published in the ABM newsletter), then there is an obligation to continue assessment and follow-up. (In this particular case, the mother had been on several rounds of Diflucan, as suggested by several LCs. By the time the physician saw her, she had a bacterial infection in her nipples, plus Raynaud's. Her pain was never yeast.)

It is a complicated situation, and we all have to figure out where we are comfortable on the continuum of practice.....

warmly,

Nikki Lee RN, MS, Mother of 2, IBCLC, RLC, CCEcraniosacral therapy practitionerFaculty, Lactation Division Maternal-Infant Program, Union InstituteFilm Reviews Editor, JHLwww.breastfeedingalwaysbest.com

[Guest guest]

ok, but the corner store sells medications, herbs and antifungals - does that give *them* prescriptive ability? the doctors *do* have prescriptive ability, but generally don't *sell* medications (except NDs who do sell herbs, etc.) i am just playing hte decil's advocate here, so i hope this doesn't offend. i understand this is your perspective, but as we have seen already on this list, amongst ibclcs there does not seem to be a consensus. is this *in writing* anywhere? thanks!

Lyla

-----Original Message-----From: [mailto: ] On Behalf Of nleeguitar@...Sent: Friday, May 19, 2006 6:07 AMTo: Subject: Re: 2 questions for those in private practice

ibclcs who do this as a convenience for their clients (not even as money makers) i am just curious how that fits with the code of ethics. any thoughts on that?

Selling herbs or anti-fungals is no different to selling any other medication. As IBCLC does not give us prescriptive ability, we are not legally protected for this act. It could be construed as practicing medicine without a license.

warmly,

Nikki Lee RN, MS, Mother of 2, IBCLC, RLC, CCEcraniosacral therapy practitionerFaculty, Lactation Division Maternal-Infant Program, Union InstituteFilm Reviews Editor, JHLwww.breastfeedingalwaysbest.com

[Guest guest]

We simply don't have enough studies -- we need hundreds more on the more practical aspects of lactation management so that we can practice with GOOD evidence behind us.

Amen!!

It is easy to publish a letter to the editor of JHL. Letters are not peer-reviewed and often serve as the start of a serious investigation. So dear colleagues, if you have some success, please, pretty please, publish it.

As an example, there were several letters published a few years back about the impact of circumcision on breastfeeding.

warmly,

warmly,

Nikki Lee RN, MS, Mother of 2, IBCLC, RLC, CCEcraniosacral therapy practitionerFaculty, Lactation Division Maternal-Infant Program, Union InstituteFilm Reviews Editor, JHLwww.breastfeedingalwaysbest.com

[Guest guest]

thanks kathy, so interesting, the variable approaches amongst those on the list.

Lyla,

State Farm provided me with the general liability insurance coverage for my freestanding office, at a pretty reasonable rate.

I carried fenugreek, blessed thistle, sage, gentian violet, and rescue remedy. However, they were not for sale without a full consultation, and clients were instructed to check with their health care provider prior to use of any alternative therapies. Clients were also screened for allergies, diabetes, hypoglycemia, etc. prior to discussing herbs.

Kathy Parkes, RN, IBCLC, RLC

The Lactation Connection (TLC) Inc.

[Guest guest]

the link really doesn't talk about distribution or sales. it just talks about referring to a HCP for consultation, and how IBCLCs are not prescribing, but "suggesting". it still feels like we, as a profession, are all over the board with this matter!

Lyla

-----Original Message-----From: [mailto: ] On Behalf Of nleeguitar@...Sent: Friday, May 19, 2006 9:17 AMTo: Subject: Re: 2 questions for those in private practice

ok, but the corner store sells medications, herbs and antifungals - does that give *them* prescriptive ability?

Thanks for this discussion.

A layperson is free to buy and use whatever they choose.

The difference comes when a person comes to a LC, a healthcare professional, for assistance. By virtue of training and education, healthcare professionals are supposed to know the limits of their scope of practice.

As a nurse or a LC, I have no prescriptive authority. I can refer to a certified herbalist or to a homeopath or to a chiropractor, I can suggest that there are other ways to deal with a situation. But I can't sell products or distribute them, or prescribe them.

I think the IBLCE link that sent tells the same story.

warmly,

Nikki Lee RN, MS, Mother of 2, IBCLC, RLC, CCEcraniosacral therapy practitionerFaculty, Lactation Division Maternal-Infant Program, Union InstituteFilm Reviews Editor, JHLwww.breastfeedingalwaysbest.com

[Guest guest]

Even if a professional code of ethics permits a certain action, personal ethics may not. Ethics is a huge issue that transcends any profession's code of ethics. Ethical codes are dynamic representations of our ever-changing understanding. And, as I learned when I created my presentation on ethics, culture, and breastfeeding, there is really relatively little in the literature on ethics & breastfeeding, ethics & culture, and nothing at all that I could find on the overlap of ethics, culture & breastfeeding (I'd like to come up for air to write an article based on my presentation). Furthermore, what a dual-professional (e.g., IBCLC/mental health practitioner; IBCLC/RN; IBCLC/herbalist; IBCLC/CST practitioner) can do, a mono-professional may not be able to do. Combining two sets of ethics, evidence-bases (or lack thereof), etc. from two different fields has additional challenges.

These kinds of conversations are so important. I'm glad you posed your question, Lyla. And, I'm glad several people have shared their thoughts. There are rarely simple answers when it comes to ethics.

-- Good Mojab, MS clinical psychology, IBCLC, RLC, CATSM LifeCircle Counseling and Consulting, LLC Website: www.lifecirclecc.com Phone: Email: admin@... Ammawell Website: http://home.comcast.net/~ammawell Announcement only email list: ammawell-subscribe

-------------- Original message -------------- From: nleeguitar@...

The challenge here for us, to bring in another discussion stimulator, is how we look in the professional arena when we suggest non-evidenced based measures to our clients?

************************************

Such as CST?

Absolutely!

One of the ways to figure out ethical decisions is to look at harm versus beneficience. Are babies hurt by CST? Are mothers? Is breastfeeding?

That can help in such decision making.

Whereas if a LC suggestions something and the mother continues to have burning nipple pain, (as in a case study published in the ABM newsletter), then there is an obligation to continue assessment and follow-up. (In this particular case, the mother had been on several rounds of Diflucan, as suggested by several LCs. By the time the physician saw her, she had a bacterial infection in her nipples, plus Raynaud's. Her pain was never yeast.)

It is a complicated situation, and we all have to figure out where we are comfortable on the continuum of practice.....

warmly,

Nikki Lee RN, MS, Mother of 2, IBCLC, RLC, CCEcraniosacral therapy practitionerFaculty, Lactation Division Maternal-Infant Program, Union InstituteFilm Reviews Editor, JHLwww.breastfeedingalwaysbest.com

[Guest guest]

yes, indeed cynthia - and these personal ethics questions are exactly what are confounding me - my personal ethics make it very difficult for me to *not* share information about "alternative" therapies i feel would be helpful - i feel it is withholding information. now selling products is a different issue, i understand, but there is definitely a gray area there as well, in terms of convenience for the family, etc. thanks everyone for the interesting discussion!

Even if a professional code of ethics permits a certain action, personal ethics may not. Ethics is a huge issue that transcends any profession's code of ethics. Ethical codes are dynamic representations of our ever-changing understanding.

[Guest guest]

It is a complicated situation, and we all have to figure out where we are comfortable on the continuum of practice.....

Amen to that, Nikki!!!

Just finished my "baby's" college graduation ceremony from University, and we are staying with my daughter and her husband in their new little house "The Dumpling" just north of Indianapolis. Truly a rite of passage for the parents when the baby finally graduates.

Sigh.

Janhttp://www.motherofbridebyjan.blogspot.com/Torrey's Blog