El Genograms Practical tools forfamiy physicians

IAN WATERS, MSW, CSW WILLIAM WATSON, MD, CCFP WILLIAM WETZEL, MSW

GENOGRAM IS A VERSATILE systems 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 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.

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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. Genograms can also be effec- cal in a busy office practice because they tive for evaluating the problems ofpatients increase the amount of time spent on the with multiple vague complaints. family history section of the office visit.'3 By doing a genogram with Nuala Family physicians who have successfully (Figure 2), I was able to enhance our rap- integrated genograms into their practices port. Often demanding, difficult, and angry acknowledge that the genogram process patients, as well as patients whom physi- increases the length ofvisits. However, they cians dislike, respond well to being involved also believe that the extra time required is in completing their genograms. The often well spent building patient rapport or genogram process frequently lets patients providing potentially useful family infor- and physicians escape from what feels like mation that can be used to address a an unproductive relationship. Patients patient's concerns during a particular interpret the genogram process as an act of office visit or at some future visit. being listened to and cared about as people. It is also important to note that a The process permits physicians to learn genogram is rarely completed in one office more about patients' life experiences, and as visit and is often constructed with a patient a result, to be more empathic to patients' over tirne. For example, many physicians needs and behaviours (Figure 3). The new construct a skeletal genogram when they insight and empathy can in turn be used to first meet a patient, and then expand it facilitate a more effective and satisfying doc- when indicated. Often, the genogram is tor-patient relationship for both patient and kept in a special place in the chart physician. The increased rapport often (eg, attached to the back) so that it can be Table 2. Benefits of means patients are more open and accepting easily located, and therefore referred to genograms of both medical and nonmedical referrals. and built upon repeatedly. Completing a genogram also commu- The other criticism of genograms is SYSTEMATIC MEDICAL RECORD KEEPING nicates a message to a patient that a fami- that, to date, research has not proven the * Easily read, graphic format ly physician is interested in addressing clinical utility of this family assessment * Identifies generational, family and psychosocial problems as part tool.'0,'247 However, studies have shown biomedical, and ofongoing health care. Many patients and that the genogram process captures more psychosocial patterns physicians find the genogram a nonthreat- psychosocial and biomedical information * Assesses connections ening way of inquiring about potentially than traditional history taking.'4"15 The between family context and sensitive issues, such as sexual abuse and results ofthese research studies should not illness alcoholism.7"2 discourage family physicians from using The visual impact of genograms can genograms (only 10% to 20% ofinterven- RAPPORT BUILDING also be useful for both physicians and tions used in medicine are * Nonthreatening way to supported by obtain emotionally laden patients in determining whether presenting randomized control trials'8). Future information medical problems are connected to family genogram research should focus on exam- * Increases trust and patient or psychosocial issues. Family physicians ining whether there is value in having a compliance can quickly look at complex medical and genogram as baseline information for * Demonstrates interest in relational genograms and understand how every patient's chart and what specific patient and significant family information could affect patients' patients, or particular patient problems, others presenting complaints. On the other hand, could benefit from genograms. 19 * Reframes presenting patients are often struck by recurring pat- problem for patients terns in their families, such as alcoholism Conclusion and cardiac problems. This information A genogram is a practical clinical tool that MEDICAL MANAGEMENT AND can influence patients' awareness, and fos- fosters a family systems approach to PREVENTIVE MEDICINE ter a sense of urgency to deal with and * Highlights supports and patient care. Genograms give family obstacles to compliance make decisions about complying with sug- physicians a quick, integrated picture of * Identifies life events that gested medical regimens (Table 28).9 patients' biomedical and psychosocial his- could affect diagnosis and tories. Genograms allow family physicians management Potential roadblocks to using to diagnose and manage difficult biopsy- * Identifies illness patterns; genograms chosocial clinical problems that often can facilitates patient The main concern expressed by family not be addressed using the traditional bio- physicians is the length of time it takes to medical model. Genograms also assist Adaptedfrom McGoldrick.8

Cnadian Family Physician VOL 40: Febmagy 1994 285 Ftgur 3. Peter T.'s genogram Thepatient complain ofcestpain.

_Iuiwi sht hP eterT.'s ,--_ I6UF~~~A U6E AM 52 ~ 50.WHACfI. Im * Patient's relationship CA with his mother-in-law; * Patient's unresolved griefafter the deatli ofmother-in-law-, (anniversary reaction); and * Patient's somatization as a response to losses and stressors. I . .,|.".S!...T.....!...... , . , .. -

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Case 2. This case study and genogram were drawn from St Michael's Hospital Family Practice Unit.

Peter T. was a 28-year-old married colleagues had left the company a month When I suggested that often the most dif- man of Portuguese descent who had ago to establish their own business, and ficult things to discuss are the most been a patient of mine for about 2 years. they wanted him to join them. He had important ones to talk about, he became My previous contact with him had been been ambivalent about this, but finally tearful and began to express how much minimal, consisting of an annual physical decided to remain with his company. he missed his wife's mother. examination and a couple ofvisits regard- 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 ofhim were higher. that he was very close to her and in fact, ic, he was obviously agitated and dis- I established a working diagnosis ofcos- "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 appar- having 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 anxiety- don'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 ofany serious physical similarities or parallels between that situa- that he was worried that he might have health problems. tion and the recent changes at his work- some 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, com- tion 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; how- likely 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."

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