Genograms: Practical Tools Physicians
Genograms: Practical Tools Physicians
Genograms: Practical Tools Physicians
Genograms
Practical tools forfamiy physicians
GENOGRAM IS A VERSATILE
SUMMARY
A geogram can help a physidan
ietegrate a patient's family
information into the medical
proMmn-solving process for
letter patient care. A genogram
allows a physid. to obtim
medicol and psychosodal
information from . patint
easily aid, as a result, to have a
hifer understanding of the
context of the presenting
symptoms.
RESUME
Le g6nogromme est n outil
qui penmet au m6dedn de
mieux int6grer les donnees
famliales du patient dons le
processus m6dKald solution
de problimes, donc d'am6liorer
la qualite des soins. Grace au
1994;4,082-287.
I
282
Construcing a genogram
Symbols for genograms have been standardized, enabling physicians to build a
X~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~....
During the first visit with complex families, a genogram is best limited to only
two generations, or to only family members with significant health problems.
Missing family data can be added later if
necessary. Family physicians should consider completing expanded genograms
when confronted with patients or families
with difficult clinical problems (Table 1).
Expanded genograms focus on three-generational relationship patterns and usually
take 20 to 30 minutes to complete.3'7'9
Physicians wanting to adopt a family systems orientation to patient care will often
start with a basic, or "skeletal," genogram.
Completing a skeletal genogram with a new
patient is frequently an effective way to
develop baseline data on who the other
family members are, who lives at home,
what this patient's context is, and what the
family's patterns of illness are. The skeletal
genogram takes 5 to 20 minutes to complete
and is limited to questions of family structure, significant family events, and history of
family health problems. Often a skeletal
genogram can be completed while recording a traditional family history.
Benefits
The information recorded in genograms
assists family physicians to generate
hypotheses about patients' risks for familyrelated illnesses or stressors, such as diabetes, hypertension, coronary heart
disease, substance abuse, and depression.
A family history of these problems often
allows a family physician to generate a
hypothesis about a patient's presenting
complaint quickly and then develop questions that help in coming to a diagnosis
and management plan.6 For example, for
a patient with gastric complaints, a
genogram that indicates a strong family
BIOPSYCHOSOCIAL ISSUES
* Anxiety, depression, or
panic attacks
* Substance abuse
* Multiple somatic or
vague complaints
* Noncompliance
PSYCHOSOCIAL ISSUES
* History of physical, sexual,
or emotional abuse
* Childhood behaviour
problems
* Difficult life cycle transition
DOCTOR-PATIENT ISSUES
* Angry or demanding
patient
* Patient whom
physician dislikes
283
,m
hp
I'kI'Ls
.ik
Gro
Rome
boyfizend;
imitedsupport jts
(e& -family and friends); and
a Patient's stomach problemns
were likely a combination of
her ncreased ol4 J|o
and her intern Iizaon of
L1.J W
36
stress..
Case 1. The following case study and accompanying genogram were taken from Dr William Watson's practice.
first met Nuala on a busy afternoon,
after she was referred urgently by her
sister who worked as an emergency room
nurse at the local hospital. Her sister said
only that she was having lots of stomach
problems and was under a lot of stress.
When I met this 38-year-old woman, she
looked depressed and tired with slightly
bloodshot eyes.
When asked why she was coming to see
me, she said somewhat angrily, "I've been
to see three doctors so far and none of
them could help me with this stomach
problem." I suspected at that point that
she might be a difficult patient. She complained of dyspepsia symptoms including
heartburn, bloating, and epigastric discomfort for the past 6 weeks. She had no
nocturnal pain or melena. She had tried
antacids with no relief. When asked what
she thought was causing her symptoms,
she said she thought it might be an ulcer. I
asked her about alcohol intake and she
indicated that she had increased from two
to three drinks a day. She also stated that
she smoked 20 cigarettes a day. At this
point she became very impatient, saying
she had to get back to work. As her
I
284
her mother
alcoholism.7"2
The visual impact of genograms can
also be useful for both physicians and
patients in determining whether presenting
medical problems are connected to family
or psychosocial issues. Family physicians
can quickly look at complex medical and
relational genograms and understand how
family information could affect patients'
presenting complaints. On the other hand,
patients are often struck by recurring patterns in their families, such as alcoholism
and cardiac problems. This information
can influence patients' awareness, and foster a sense of urgency to deal with and
make decisions about complying with suggested medical regimens (Table 28).9
complete a genogram. Some family physicians consider genograms to be impractical in a busy office practice because they
increase the amount of time spent on the
family history section of the office visit.'3
Family physicians who have successfully
integrated genograms into their practices
acknowledge that the genogram process
increases the length of visits. However, they
also believe that the extra time required is
often well spent building patient rapport or
providing potentially useful family information that can be used to address a
patient's concerns during a particular
office visit or at some future visit.
It is also important to note that a
genogram is rarely completed in one office
visit and is often constructed with a patient
over tirne. For example, many physicians
construct a skeletal genogram when they
first meet a patient, and then expand it
when indicated. Often, the genogram is
kept in a special place in the chart
(eg, attached to the back) so that it can be
easily located, and therefore referred to
and built upon repeatedly.
The other criticism of genograms is
that, to date, research has not proven the
clinical utility of this family assessment
tool.'0,'247 However, studies have shown
that the genogram process captures more
psychosocial and biomedical information
than traditional history taking.'4"15 The
results of these research studies should not
discourage family physicians from using
genograms (only 10% to 20% of interventions used in medicine are supported by
randomized control trials'8). Future
genogram research should focus on examining whether there is value in having a
genogram as baseline information for
every patient's chart and what specific
patients, or particular patient problems,
could benefit from genograms. 19
Conclusion
A genogram is a practical clinical tool that
fosters a family systems approach to
patient care. Genograms give family
physicians a quick, integrated picture of
patients' biomedical and psychosocial histories. Genograms allow family physicians
to diagnose and manage difficult biopsychosocial clinical problems that often can
not be addressed using the traditional biomedical model. Genograms also assist
Table 2. Benefits of
genograms
RAPPORT BUILDING
* Nonthreatening way to
obtain emotionally laden
information
* Increases trust and patient
compliance
* Demonstrates interest in
patient and significant
others
* Reframes presenting
problem for patients
Adaptedfrom McGoldrick.8
285
,--_
52
U6E AM
* Patient's relationship
with his mother-in-law;
* Patient's unresolved
grief after the deatli
of mother-in-law-,
.
50.WHACfI
Im
CA
(anniversary reaction);
and
* Patient's somatization
as a response to losses
and stressors.
I
. .,|.".S!...T.....
!..............
. ., . , .. .
... ...
.....
,.
...~~~~~~~~~~~~~~~~~~~~~~~~100
.....
Case 2. This case study and genogram were drawn from St Michael's Hospital Family Practice Unit.
T. was a 28-year-old married
of Portuguese descent who had
been a patient of mine for about 2 years.
My previous contact with him had been
minimal, consisting of an annual physical
examination and a couple ofvisits regard-
colleagues had left the company a month When I suggested that often the most difago to establish their own business, and
ficult things to discuss are the most
they wanted him to join them. He had important ones to talk about, he became
been ambivalent about this, but finally tearful and began to express how much
decided to remain with his company. he missed his wife's mother.
Consequently he now had a more senior
She had died the previous year after a
ing minor infections.
position with his company and felt that yearlong battle with cancer. Peter stated
When Peter came to see me at the clin- expectations of him were higher.
that he was very close to her and in fact,
ic, he was obviously agitated and disI established a working diagnosis of cos- "she was more like a mother to me." As
tressed. He reported that he had been tochondritis, prescribed some coated we discussed this further, it became apparhaving some chest pain associated with aspirin, and suggested that Peter return to ent that Peter's grief regarding this loss
dyspnea during the past 10 days, and that the clinic in 1 week. Three days after the was unresolved, as he had tried to remain
he had had to leave work and go home initial visit Peter phoned me in a very agi- strong for his wife and her family at the
early on a couple of occasions. As Peter tated state, saying that his symptoms had time of the death. In addition, Peter and
talked about this, he was extremely anxious not improved at all and that he in fact had his wife took on increased responsibilities
and shaky. When I asked him what he to leave work early that day due to his for the extended family after this death,
thought was going on, he initially said, "I chest pain. I tried to reassure him by demands that were difficult and anxietydon't know; that's why I came to see you." telling him that his chest x-ray examina- provoking for them.
However as I persisted in trying to under- tion results were normal and that there
When I asked Peter if there were any
stand his concerns and fears, he indicated were no indications of any serious physical similarities or parallels between that situathat he was worried that he might have health problems.
tion and the recent changes at his worksome problem with his heart.
When Peter came in for a follow-up place, he was able to identify that in both
While I did a physical examination, I appointment, he was again very anxious situations he had lost people about whom
inquired about the various risk factors and reported no significant change in his he had cared and on whom he had
associated with heart disease, and discov- presenting problems. I explained to Peter depended. I also indicated to Peter that he
ered only one factor in his case (ie, his that often many factors contribute to was likely experiencing an anniversary
father had been diagnosed with angina symptoms such as his, and that to under- reaction to his mother-in-law's death,
about 4 years earlier). The examination stand these more clearly I needed to which was a normal and healthy part of
revealed minimal tenderness along the left obtain more information.
his grieving process.
parasternal region with no other positive
I proceeded to construct his family
I explained to Peter that unresolved
findings. I ordered a chest x-ray examina- genogram (Figure 3). As I asked Peter grief and other stressors in his life, comtion and did a cardiogram in the office questions about his own family, his bined with his anniversary reaction, were
(which was normal).
responses were quite matter-of-fact; howlikely the primary factors contributing to
Because I wondered whether Peter's ever, in contrast, he was cautious and his current symptoms. I suggested referral
symptoms were related to stress, I inquired apprehensive when talking about his to a social worker for counseling, and
about any recent changes or pressure in his wife's family. When I commented on this Peter accepted this saying, "Talking about
life. He told me of significant changes in observation, he indicated in a sad tone these things with you today has helped me
his work situation: some of his senior that it was difficult for him to talk about it. to see that they still bother me."
Peter
man
286
References
1. Campbell T. Family interventions in physical
health. In: Sawa R, editor. Family health care.
Newbury Park, Calif: Sage Publications,
1992:213-26.
2. Barrier D, Christie-SeelyJ. The presentinig
problems of families and family assessment.
In: Christie-SeelyJ, editor. Working with the
famil in primagy care: a systems approach to
health care and illness. New York: Praeger,
1984:201-13.
3. Mullins H, Christie-SeelyJ. Collecting and
recording family data - the genogram. In:
Christie-SeelyJ, editor. Working with thefamily
in primagy care: a systems approach to health care and
illness. New York: Praeger, 1984:179-91.
4. Barrier D, Bybel M, Christie-SeelyJ,
8(l):8-10.
10. Rohrbaugh NI, RogersJ, lIcGoldrick NI.
How do experts read family genograms? Fan7
Systems Med 1992; 10(l): 79-89.
11. Radomsky NA. Creatinig inews meaniitng
through dialogue. A case story of chronic pain
\
;0f.E=i50000
0
fffffffffff
f
ffFf000:ffff0
LSo||
IL
tt000000
t00000000
00:00:
0:00
. ;02lDQ;::0t
77
t0:X;t
E:
\XIFAA -~~~~~~~~~~CCP
-
i0:00:S M
i0
00000
tm f