74 | The Lactation Client Journey Inside Private Practice

Annie: Well, hey there, Leah. Hey Annie. How are you? I am great. How are you?

Leah: It's doing good. Made it through the first part of the holiday, so I'm feeling like, okay, now we're in the home stretch for, the second part of the holidays and into the new year. So making it through Thanksgiving is always a feat.

Annie: It's such a wild time of year and it's birthday season for my family also. My husband and I celebrate our wedding anniversary in December so it always feels like such a wild ride. But we started our holiday season with the flu and it was so funny because we're like, well it could be a lot of things but the one thing we know it isn't is we know it's not Covid. We took about a hundred thousand Covid tests at home because my kids bring them home from school like cartons. They just hand them out.

Leah: Oh my gosh.

Annie: They hand them out like nipple shields in the hospital at the New York City Public School.

Leah: Oh my gosh, that's so funny. It's weird now because I'm like they need to start making those for all, like flu and RSV. It would be so nice if we had those all at home and then we would know like, okay, we need to be more careful. I've got the flu or whatever. Crazy how we have those for Covid and they're everywhere. So now we know that that's possible. So come on big pharma make that happen.

Annie: Yeah, absolutely. I was totally wishing for a flu test because like we say we have the flu. We think we have the flu but we didn't go to the doctor for it. We just waited it out. Nobody was that sick.

Leah: Boy that knocks you down.

Annie: It really does. You can hear my voice is still a little gravelly and it's been two weeks. I'm still dealing with things, but I wear my mask, and I wash my hands. I do all the things to keep the family safe so that's all you can do.

Leah: Yeah. Yeah, definitely. Well, I'm excited about our talk today because we're talking about how the client basically has a journey through our private practice as they work with us. I think this is such a fun topic because sometimes if you're just starting to think about being in private practice, you might not be thinking about all the aspects and how the whole journey might unfold. So it's a fun topic and for you and I, this is something that's just every day. This is what we do, but for people that are just curious about private practice or just getting started out, I think this information will be really handy.

Annie: I agree. I love this topic because, well, first of all, I love the idea of a journey or a story, and that's just the storyteller in me. I just love thinking about the different shifts and changes and moments throughout my relationship with my clients, especially with the pleasure of being able to work with so many of them over multiple visits and across time. That has been so wonderful. It's something that we kind of, at least I had when I was a Leche League leader, you have people come every week and you really get to hear their story and you get to see how things unfold. Then when I started private practice, I was like, oh, they only see me one time because that's all they can afford. Then you're missing so much of the picture. So when I switched to taking insurance and it got me back, it's like you know what, I'll put up with the heartaches of insurance for the joy of getting to support families across multiple sessions.

Leah: I do think it's so powerful and it actually one thing that I feel it's so valuable in is actually honing my skills too. Not only do I get to support the family over time but you really get to see the outcomes unfold and see what strategies are connecting for what people, what's not connecting for what people. I really feel it's such a beautiful way to hone your skills because you get to see how things unfold with the strategies you might be giving information on and helping parents create. It's like, oh okay, this didn't seem to go so well. Why is that? You know really getting to pick through, okay, this mom was feeling really stressed with this strategy. Okay, maybe I could come up with some other ideas. It's just like, I dunno, I feel like it's made me really focused on my skills.

Annie: I totally agree about honing skills. Just really kind of getting a chance to experiment and try things because you'll get feedback the next week or two weeks later or a month later, depending on how you're seeing them. I think a big part of the challenge, really of managing these cases and looking at the journey across time, is what the client is imagining or wanting. We have to manage those expectations about what our role is and how we can best support them. Some of them come to us, there's a range. We have some that are completely skeptical and they're not sure that we can help them at all because they're like not sure that, maybe they've been told breastfeeding is natural and you just should do it, mama. All of those messages that are out there. And then on the other extreme, we have the people that expect us to have that magic wand that I'm still looking for it. It's on my wishlist for the holidays. If anybody's shopping for me, I want that lactation magic wand. We have to figure that out with them, starting with scheduling and that is a big piece of it. It's such a big thing for them to come for that first visit, and they bring in a lot of high expectations and to really establish right off the bat that for the most part, any situation really does best with at least two. At least two. Let's try this and check-in in a week. So helping them see right off the bat that we are looking at making time in their schedule for a follow-up session with us, and also me making time in my schedule to make sure that I've got room and space to accommodate those existing clients. How do you manage that scheduling piece, Leah?

Leah: Yeah, well I definitely try to limit the number of initial visits per week because I do really encourage follow-up visits, even for my non-insurance patients. We actually keep the cost of follow-up visits, we try to keep it reasonable for the sheer sake of it, I know my outcomes are better when I can get those follow-ups in with the families. So it is really important for me that I can give my best service to them when they can have these multiple visits. So from a financial perspective, but also from a scheduling perspective. I really am conscientious of taking on too many initial visits per week because I know I'm gonna need to have space for those follow-ups the next week. My scheduler is really conscientious of this too and she knows that most of my clients are going to have a follow-up visit. It's just a rare instance where we won't meet more than once. So my admin definitely is aware of that. Then the other piece of it is those setting expectations. It could be some wording and language on your website about this is how your journey with us is gonna go. I think that's really helpful. Even in the booking section to actually say like most clients benefit from more than one visit. We'll discuss your needs during the initial visit but even having that language there from the get go, I think really gets their head around the time and financial investment that will be there, but we'll give them the best chance for the outcomes that they desire. I also think talking about it in the visit. I'll definitely be talking about, okay, when we follow up, we're gonna go through these things. So today we're gonna focus on this and then when we follow up, we're gonna focus on this and we're gonna be checking in about this. And really helping them see the value in the follow-up so that they know this is what we can manage today and this is what we're going to tackle next time or what assessment we're gonna need at the next visit. I think that by incorporating that and weaving it throughout the whole visit from really throughout their whole contact with you from the time they get on your website and look at the scheduling page to the entire time they're scheduling with you. Then also when you're visiting with them, weaving in this idea that yes, this will be necessary, these follow-up visits. I think it really helps them and they really see the value in it and they get the buy in. They're like, yeah, I can see where that would be so helpful and they desire it because they understand it. That's so valuable for them to see how valuable it is, but you might not realize how valuable it is until somebody explains that to you.

Annie: Definitely. And along with that, what I like to do is I like to give them the tools. Okay, let's say you never saw me again. I do want my clients to have tools in their hands where they can manage things themselves for whatever outcome and that might be the right decision for them. So I never want any of my clients to feel like I'm withholding information to make them dependent on me or even that I'm giving them information that makes them, in a way, that makes them dependent on me. I don't want my clients to feel dependent on me or to feel like our relationship is a requirement for them to live a bountiful life with their baby At the same time, like you said, I want them to understand what I bring and how we do need to see some of these things kind of cook. You know what I mean?

Leah: Yeah, there's some stuff you just can't figure out until you see it unfold. Yeah.

Annie: Then I will come in and I will do X, Y, and z and I will update the care plan and here's what that's gonna look like. You talked about pricing with your follow-ups. I also do the same where I do discounted follow-up because I wanna encourage that. At the same time though, I don't wanna put myself in a position where I'm like, oh, I don't wanna do a follow-up because I priced it too low. ' rather book one of those juicy initials. So there is a balance there too. But what I have done is I hold kind of firm for visits two and three at the follow-up price but then if we're looking at a fourth visit often I'll be like, listen, if I know it's just gonna be a half an hour and I'm already in the neighborhood, I will do a discount for that. I also have my office as an option, come in for a weight check, I can discount that. For self-pay clients, I really do try to not make it be just about the money as well and help them to see that I'm not in this for the money but that I am in this to get paid. This is my job.

Leah: I gotta pay my bills.

Annie: Exactly.

Leah: I do think it's so important to equip them with skills, but also it can be so overwhelming to try to give every bit of information that you're ever gonna need for your lactation journey in one visit. I try to help them understand that there's only so much I can teach you in one two-hour period and I will overwhelm your brain and you'll leave here burned out already because the idea of all these upcoming steps. So I think, like you said, it's so good to really equip them but also help them see how not to get overwhelmed in the lactation physics. Like you said early on when we were thinking, okay, I gotta get everything done in this one visit because I don't wanna burden them with the second visit and then it was like, oh wait, these poor parents are so overwhelmed because I'm trying to map out the next month of care in one visit. Okay, if this happens, do this. If that happens, do this. I mean it's definitely overwhelming. So I think we can definitely, these setting expectations and being really open with them and helping them understand. Then if there is some, like I can't only do one visit, either working with them like you're talking about making sure they have resources and set them up for managing some of that themselves. I just think this open communication about all aspects of your follow-up plan is so important. That will also entail coordinating their care with referrals they might need and having those really good connections with those referral bases I think is so important to help the client. I guess this a little bit falls under setting expectations is to help the client understand that I'm not a solo, like only me, and I'm gonna solve all your lactation issues alone as one party gonna do it all. No, it's this community that we're gonna come around this family and it's rarely ever just me. It's oftentimes referring out. Is that the same for you?

Annie: Yeah, definitely. It's never just me. I mean that's also because I do take this very client-centered approach, which is that it's them and their support network. I'm there to work, to build and strengthen their support network because that's what's gonna carry them for the rest of their lives. I'm only in their life for a short period of time. They need to have what they need to really go forward. That could be really making sure that their pediatrician has good information. It's also about bringing other, if they need frenotomy, if they need body work, if they need both if there's another specialist that needs to be brought in like sometimes we're referring to a pediatric GI for digestive issues and making sure that my clients are getting the best of the best. I'm giving them like, this is who I think you should be seeing. We're actually doing in a couple weeks on December 19th, we're doing a deeper dive into watchful waiting with Susan Howard, who's an IBCLC in Virginia, and the idea of watchful waiting being that we are actively waiting for something to happen. We don't have the answers right now. We have to see how things play out. That also has a lot to do with these clients that have these complicated cases where you have a baby who needs body work. Then probably needs to have a tongue tie released and then it's gonna need body work after it needs lactation support in there. The parent might need mental health support as well. You get sometimes these cases, I mean, you know, like the ones that really break your heart. The most are a baby who can't latch and a parent who can't bring in a full milk supply and you're like that only time. This watchful waiting can really negotiate that situation but I don't want them to be alone and I don't wanna be the only person watching and waiting with them.

Leah: Absolutely. Yeah. I think it's so important to have that kind of vantage point of watchful waiting and then communicating with the client that there's just only so much that we can figure out in this visit. Without time on our side to show us how things unfold because so many of these things require time to see what is going to come of both our interventions, but also just like natural biological processes. So it's, definitely so helpful to have that and I love the terminology around that.

Annie: Yeah, and I work with clients, I know you have them too, where I'm identifying that this baby meets all the requirements for a specialist referral for tongue tie. I'm using my screening tools and I see all these things and I communicate it to the family and they don't want to act on that. The baby has, tension that is visible and sometimes even the parents can see it. A lot of times they can is what I find is that they're like, oh yeah, I totally noticed that about my baby. So we do need to give them this vocabulary to say, listen, the decision of what you're gonna do with your body and your baby is up to you. It's not up to me. I'm here to support you regardless of whatever path you take. I'm here for you. Here are the things that we're watching together and these are the signs that I just want you to see what we're looking. That they can be empowered to say, okay, yeah, we did decide to wait and see, but now we've waited and I see what you're talking about and yes, let's move forward. It's hard. It's hard because I wanna go in and I kind of wanna tell them what to do, but I can't tell them what to do. That's not my role.

Leah: Not my body, not my baby. Yeah, yeah, absolutely. I know that's, really challenging. I have seen it go so many different ways. The way I thought it was gonna go and then it doesn't go that way and the way unexpectedly goes. So it's like we also have to remember that we don't have the crystal ball either. Sometimes that tincture of time really helps us see how things unfold and helps guide us. I think one of the beautiful things about being in private practice and getting to have this, like we were talking about getting to see these different outcomes kind of unfold in front of us is that we can be there and continue support and shift the way we support based on these different ways that things unfolding and the outcomes that are developing.

Annie: Yeah, absolutely. It's the outcome that we don't know. We never know the outcome and there are different types of outcomes that we're looking at and they require different kinds of approaches to closure. So you see the outcomes where you actually get to be there for it. Where you get that nice like you graduated.

Leah: Yes. I love those.

Annie: And those are great, obviously. The more I do this and the more skilled I get and confident I get, the more of those kinds of outcomes I do get a chance to see. A lot of that is just being confident in saying we're gonna need multiple visits for this. We also have those outcomes where we're like, things didn't go the way the client wanted them to. Things didn't necessarily go the way we hope they would do. You know you try. Let's try these strategies to increase your milk supply. It didn't come up and we tried all the things. Biology just came in and said, nah.

Leah: I know and it's so hard, to manage that because everybody had their hopes set on a different outcome. It's taken a skill and counseling skills and communication skills for me to feel like I can give good support through that, too. It's just you get really caught up and like, why isn't this working? You get as frustrated as the family is but I feel like it's taken a long time. We should do a whole episode on that, like, how to talk to families when things aren't going the way that they were supposed to go. I know somebody write that down or the way they wanted them to go or they hoped them to go because that language can be a turning point in their parenting journey. Of course, we're mindful not saying anything about failure but there's a lot of other things that we could say in that moment that could really shift the way the parent relates with their baby and their body. ,I think that's just so important to keep honing those skills because it's been something that has evolved for me over a lot of time and I feel confident now that even when biology doesn't cooperate with our best laid plans, I feel like I can give good support through that and really help the client have either closure on their journey or shift their expectation of their journey, or help them find new ways to relate to the journey that they had or they're having. But then there's those outcomes where there might be the client that you never hear from again. Those are the ones that make me sit around and go, I wonder what happened. Then a few times it has come back around where I'll see them out somewhere, like at a birth fair or something. They're like, oh my gosh, you were so helpful and I'm sitting over here the whole time was thinking like I guess things didn't work out or they changed their mind or I don't know. Then they're like, oh my gosh, we breastfed for two years and it was so amazing. Thank you so much for coming see me that one time and never heard from you again. So now I just try to imagine that if I don't hear back from someone or if they don't call back for a follow-up or whatever that that's what I just imagine. I try to just keep focused on best possible scenario because all of it is, in the end, gonna be my imagination. Whether I imagine that it didn't go well or imagine that it did go well, I don't know. I'm gonna imagine that they're out there living the journey of feeding their infant that they desired to live. Shifting that in my brain has been so helpful because in the end, if you remind yourself that whether you imagine the worst case scenario or the best case scenario, both of them are your imagination, so you might as well pick the better of the two because at least that feels better. Until you get other information, you might as well imagine that it's all going well. The funny thing is for me, it's happened more than once that I found out. It'll be like, oh my friend referred you, and I'm like, I never heard back from that friend. I can't believe they referred you. Of course I'm not saying that to them, but I'm thinking in my head like, what? They referred you? I thought they never wanted to see me again. She'll be the new parent will be like, oh my gosh and they said, you were so amazing and they had this amazing breastfeeding journey. I'm like would've been nice to know that but it's not the client's responsibility to keep us informed if things are going well for them. But how do you manage that for you, that closure when you might not actually know the end results? So many times that is the actual, how things end up for us is that we see them several times, we think going well, and we might not ever hear the end, end result. Right.

Annie: Yeah and I think for me it starts with making sure that I'm mindful of when we're wrapping up a session or I'm communicating with them by email or by text if they've got text support, that I always think like this could be the last thing I ever say to them. I wanted to feed them. I wanted to nurture them. There was a meme that was going around recently that was, somebody had posted, I wish that one of the lactation consultant, one of the many lactation consultants I saw, had told me it was okay to just give up. It was some parents speaking from their heart about what was happening in their journey. We read that and it brings up a lot of really complicated things for me at least. The word I would never say give up. I would never put it in terms of success or failure but also I really hate that this parent felt like they were trapped in something that they couldn't get out of or that they didn't feel supported in what was best for them. So I really like to, again, start by helping them really see that it's theirs. This belongs to them and not to me. So that I support them and letting them choose their language and then using their language to describe what they're going through and what they're dealing with. So not putting words in their mouth but if my client said I really just wanna give I might say, it's okay to give up and then I'll follow it by something. I'll try to think of what is the most positive spin that I can put on the phrase give up. I'll say you're, giving up these things that aren't serving your family and you're making space for all the things that will serve your family. So I'll really try to build on what they're saying so we're not just left with like, you know what you can just give. It's giving up in everything that that means but I wouldn't use that phrase. I'm not against using that phrase because for some people that is really what it feels like. It does feel like you're somebody who's been able to strive for things your whole life and has been worked hard and done well, and gotten good grades and now here you're confronted with something that you have absolutely no control over. But everything in you says if I just try one more thing, if I just try one more thing and that your identity is really wrapped up in that idea of success over failure. I think it is important to be there with somebody who is going through that and to understand that that can be a reality for someone. Then the other piece with those outcomes where I've had the same thing where I'm like, I've never heard from you again, but I have had the surprise referral or somebody telling me, you change my life. I'm like, I never would've known. Or the people who are like, I think I really wanna become a lactation consultant. Those are always the ones that I hold in my heart forever even if they never become one. I'm like, but you wanted to, that's all that matters to me. I was researching a talk I gave this spring, which is on my website. It's called Hold on for One More Day. I gave it at the Dallas Lactation Consultants Association this summer. In the talk, I did a lot of research into burnout and the book called, that I used a lot from, was called the Resilient Practitioner. It had this concept and there was for therapists but talking about the uncertain outcome and how that the existence of the uncertain outcome is a contributor to provider burnout when you're in a helping profession. So you may not get closure with your client, they may ghost you and you have to put their outcome into a Schrodinger's box, and it's a mystery. You still have to find closure for yourself so you need to complete the stress cycle somehow. Just move your body, do some deep breathing, hug somebody you love for 20 seconds, apparently helps complete the stress cycle. According to that book, Burnout by the Naoki sisters that came out last year and celebrate the win. Then also take time to reflect and say, okay, let me just really spend a little time with this. Maybe it's been three weeks and I haven't heard from them, or I sent a text and nothing came back. Let's sit with this and let me just reflect and let me just say here's what I want to take from this to move forward. But in maybe journaling that if that's your thing, talking it through with a colleague but finding that closure for yourself in a way that is meaningful for you so that you put it in that box and move on.

Leah: And I have a literal box. I really do. I literally have a box for clients that I just, whether it be I don't know what the outcome is or it's been a really stressful case. I have a literal box that I colored and made and I'll just have a little piece of paper. I don't put any names or anything in it but just something that will remind me of that person and I just put them in the box because that feels like a really nice way to close off that. I think it's so great to reflect on what could I learn from this experience. Then like I said earlier, if you are gonna imagine anything, you might as well imagine something good. At least you're keeping good feeling inside of you and putting good feelings out into the world versus catastrophizing and thinking of the absolute worst outcomes because again, both of them are just your imagination so you might as well pick the good one, right?

Annie: All these families are going to have good things and so you can just say like they're out there living their life and enjoying their babies and maybe planning for the next one. Who knows? There, are good things in that person's life. Nothing that did or didn't happen during their lactation sessions can take that away from them or anything. So you just imagine that if you can say I gave my fullest, I gave my everything, and maybe I came up against something where I didn't give everything that was possible. So there's an area where I need to grow and that's also okay. That doesn't mean that I'm learning, it just means that I'm human and there's always more to learn. So that for me, looking for the places where I can always learn more definitely does really keep me going and does really fuel me through those uncertain outcomes.

Leah: Definitely, that's what I love to journal about is what lesson can I take from this is a prompt that I will journal about in any of these more stressful outcomes or if I'm trying to seek closure. So it's been so fun to get to reflect on the lactation client's journey through our private practices and I think this is an area that we can keep expanding on because there's so many more things I'd love to say about all these different sections that we kind of talked about here. We love to hear feedback from all of our listeners on topics and things that you guys would like to hear about as.

Annie: Yeah, and you can come to our deeper dive in December or you can purchase recordings of our past deeper dives. We have them all in a vault that you can buy and you can actually binge hours and hours and hours of deeper dives into all kinds of private practice talks. We have a subscription option so you can subscribe and come to every one of our live ones. , Like I said, we have Susan Howard doing Watchful Waiting in a few weeks. We would just love to hear from you if you have topic ideas, please reach out. Please don't be shy. We are the friendliest people you'll ever meet when it comes to lactation stuff.

Leah: Definitely. Well, it's been great talking with you today, Annie, and I look forward to our next episode.

Annie: Me too. Bye Leah.

Leah: Bye.