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Genograms Practical Tools Forfamiy Physicians

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Genograms Practical Tools Forfamiy Physicians El Genograms Practical tools forfamiy physicians IAN WATERS, MSW, CSW WILLIAM WATSON, MD, CCFP WILLIAM WETZEL, MSW GENOGRAM IS A VERSATILE Family systems medicine clinical tool that can help During the last decade, research has family physicians inte- demonstrated a relationship between grate a patient's family family functioning and the physical and information into the med- emotional well-being of an individual ical problem-solving process for better patient.' Family systems medicine has patient care. Physicians in primary care promoted a family orientation to patient SUMMARY often have to treat patients with serious care by developing several assessment A geogram can help a physidan medical illnesses (eg, cardiovascular dis- tools that incorporate both family ietegrate a patient's family and information into the medical ease, diabetes, hypertension) in combi- psychosocial information into medical proMmn-solving process for nation with psychosocial problems care. These family assessment tools letter patient care. A genogram (eg, domestic violence, substance abuse, include the family APGAR, family circle allows a physid. to obtim relationship difficulties). Knowledge of method,2 genogram,3 PRACTICE,4 and medicol and psychosodal both biomedical and psychosocial issues FIRO5 models. information from . patint is needed to diagnose and manage these Physicians using a family systems easily aid, as a result, to have a patients. The family genogram (family medicine orientation have found that hifer understanding of the tree) offers a unique opportunity for creating a diagram of a family's health context of the presenting obtaining family medical and social his- care problems assists them in managing symptoms. tory from patients more easily, and for many of their patients' health care con- expanding a family physician's under- cerns. Genograms have been compared RESUME standing of the presenting problems by to more traditional medical tools, such as Le g6nogromme est n outil qui penmet au m6dedn de providing a quick picture of the context x-ray films and cardiograms, that help mieux int6grer les donnees in which they occur. facilitate hypothesis generation, differen- famliales du patient dons le tial diagnoses, and ultimately a manage- processus m6dKald solution Mr Waters is a Social Worker and Lecturer; ment plan for the patient.6 "The de problimes, donc d'am6liorer Dr Watson, a Fellow ofthe College, is an genogram can be thought of as an x-ray la qualite des soins. Grace au Assistant Professor, and Mr Wetzel is a Social ofthe family... It gives the physician and genoromme, le midecn paut Worker and Lecturer in the Department ofFamily the patient a graphic display of the fam- fadlement obtenir los and Community Medicine at the University of ily, including the family's patterns of ill- informations miicales et Toronto. Mr Waters is on staffat The Toronto ness and psychosocial problems."7 psychosodales, ce qu facilera Hospital. Dr Watson and Mr Wetzel are at la comprfieslon du contexte St des symptomes de Michael's Hospital. They are all members of Construcing a genogram presentotien. the Working with Families Institute at the Symbols for genograms have been stan- C mFH 1994;4,082-287. University of Toronto. dardized, enabling physicians to build a I 282 Canadian Family Physician VOL 40: Februay 1994 X~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.... picture offamily structure quickly and see During the first visit with complex fam- how it affects a patient's ability to cope ilies, a genogram is best limited to only with illness or other significant life stres- two generations, or to only family mem- sors (Figure 1).6 A genogram collects and bers with significant health problems. records three generations of family infor- Missing family data can be added later if mation in six specific categories: necessary. Family physicians should con- * family structure; sider completing expanded genograms Table 1. Issues for which * life cycle stage; when confronted with patients or families genograms might be * pattern repetition across generations; with difficult clinical problems (Table 1). helpful * life events and family functioning; Expanded genograms focus on three-gen- * BIOPSYCHOSOCIAL ISSUES relationship patterns and triangles; and erational relationship patterns and usually * Anxiety, depression, or * family balance and imbalance.A8-0 take 20 to 30 minutes to complete.3'7'9 panic attacks * Substance abuse Physicians wanting to adopt a family sys- Benefits * Multiple somatic or tems orientation to patient care will often The information recorded in genograms vague complaints start with a basic, or "skeletal," genogram. assists family physicians to generate * Noncompliance Completing a skeletal genogram with a new hypotheses about patients' risks for family- patient is frequently an effective way to related illnesses or stressors, such as dia- PSYCHOSOCIAL ISSUES develop baseline data on who the other betes, hypertension, coronary heart * History ofphysical, sexual, family members are, who lives at home, disease, substance abuse, and depression. or emotional abuse what this patient's context is, and what the A family history of these problems often * Childhood behaviour family's patterns of illness are. The skeletal problems allows a family physician to generate a * Difficult life cycle transition genogram takes 5 to 20 minutes to complete hypothesis about a patient's presenting and is limited to questions of family struc- complaint quickly and then develop ques- DOCTOR-PATIENT ISSUES ture, significant family events, and history of tions that help in coming to a diagnosis * Angry or demanding family health problems. Often a skeletal and management plan.6 For example, for patient genogram can be completed while record- a patient with gastric complaints, a * Patient whom ing a traditional family history. genogram that indicates a strong family physician dislikes Canadian Family Physician VOL 40: Februagy 1994 283 Figure 2. NuaLaK.'. gpatrem: lpat cormpaind fsh.pn mb. hp,m I'kI'Ls Gro .ik . Rome Family history of lcoholism; P*atient.s conffiu6 relationship with her father; * Recent separation fti ^r boyfizend; L1.J W 36 imitedsupport jts l (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 stress.. Case 1. The following case study and accompanying genogram were taken from Dr William Watson's practice. I first met Nuala on a busy afternoon, physical examination was normal, her mother as meek and passive. Both after she was referred urgently by her I prescribed an H2-receptor blocker and parents died several years ago. "Well, sister who worked as an emergency room asked her to return in 2 weeks. Nuala," I said, "Sometimes these experi- nurse at the local hospital. Her sister said When she returned I asked her whether ences can affect us in ways that we don't only that she was having lots of stomach she had any stressors in her life. She understand. It seems that people who problems and was under a lot of stress. acknowledged it had been difficult for her have lived in families like yours often have When I met this 38-year-old woman, she recently. She also stated that her stomach pains that doctors cannot completely fix. looked depressed and tired with slightly felt much better, and she seemed less Perhaps your pain is somehow connected bloodshot eyes. angry. I asked, "Do you think there could to your past." I When asked why she was coming to see be a connection between your stomach "Could be," she said. me, she said somewhat angrily, "I've been problems and some of the stresses in your I then completed her examination and to see three doctors so far and none of life?" She then related how she had bro- reviewed her blood test results, which them could help me with this stomach ken up with her boyfriend 6 weeks ago showed a mild elevation of liver enzymes. problem." I suspected at that point that and had subsequently increased her alco- I suggested that she would have to stop her she might be a difficult patient. She com- hol intake. She appeared upset about this excessive alcohol intake ifshe ever wanted plained of dyspepsia symptoms including and seemed on the verge of tears. She to get better. I mentioned some options for heartburn, bloating, and epigastric dis- went on to talk about how stressful her treatment and suggested she return in comfort for the past 6 weeks. She had no work had been lately. With the informa- 3 weeks for a follow-up visit. nocturnal pain or melena. She had tried tion on excessive alcohol intake, dyspep- On the third visit, she looked more at antacids with no relief. When asked what sia, and smoking coupled with a ease and healthier. She said she had she thought was causing her symptoms, demanding, stressed patient, I decided to thought a lot about what we discussed on she said she thought it might be an ulcer. I construct a genogram to gain a better the last visit, especially with regard to her asked her about alcohol intake and she understanding of family health issues and family. She recognized some patterns of indicated that she had increased from two relationships. alcohol overuse, especially in her grand- to three drinks a day. She also stated that Nuala talked about her alcoholic father, parents, father, and brother. She thought she smoked 20 cigarettes a day. At this whom she hated for constantly berating that she would seriously like to explore point she became very impatient, saying her mother and herself. She denied any alcohol treatment programs and also she had to get back to work. As her physical or sexual abuse. She described obtain counseling for her stress problems. 284 Canadian Family Physician VOL 40: February 1994 history ofalcoholism would lead to a high complete a genogram. Some family physi- index of suspicion about the possible role cians consider genograms to be impracti- of alcohol.
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