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SUMMARYA geogram can help a physidanietegrate a patient's familyinformation into the medicalproMmn-solving process forletter patient care. A genogramallows a physid. to obtimmedicol and psychosodalinformation from . patinteasily aid, as a result, to have ahifer understanding of thecontext of the presentingsymptoms.

RESUMELe g6nogromme est n outilqui penmet au m6dedn demieux int6grer les donneesfamliales du patient dons leprocessus m6dKald solutionde problimes, donc d'am6liorerla qualite des soins. Grace augenoromme, le midecn pautfadlement obtenir losinformations miicales etpsychosodales, ce qu facilerala comprfieslon du contextedes symptomes de presentotien.C mFH 1994;4,082-287.

GenogramsPractical tools forfamiy physicians

IAN WATERS, MSW, CSWWILLIAM WATSON, MD, CCFPWILLIAM WETZEL, MSW

GENOGRAM IS A VERSATILE

clinical tool that can helpfamily physicians inte-grate a patient's familyinformation into the med-

ical problem-solving process for betterpatient care. Physicians in primary careoften have to treat patients with seriousmedical illnesses (eg, cardiovascular dis-ease, diabetes, hypertension) in combi-nation with psychosocial problems(eg, domestic violence, substance abuse,relationship difficulties). Knowledge ofboth biomedical and psychosocial issuesis needed to diagnose and manage thesepatients. The family genogram (familytree) offers a unique opportunity forobtaining family medical and social his-tory from patients more easily, and forexpanding a family physician's under-standing of the presenting problems byproviding a quick picture of the contextin which they occur.

Mr Waters is a Social Worker and Lecturer;Dr Watson, a Fellow ofthe College, is anAssistant Professor, and Mr Wetzel is a SocialWorker and Lecturer in the Department ofFamilyand Community Medicine at the University ofToronto. Mr Waters is on staffat The TorontoHospital. Dr Watson andMr Wetzel are atSt Michael's Hospital. They are all members ofthe Working with Families Institute at theUniversity of Toronto.

Family systems medicineDuring the last decade, research hasdemonstrated a relationship betweenfamily functioning and the physical andemotional well-being of an individualpatient.' Family systems medicine haspromoted a family orientation to patientcare by developing several assessmenttools that incorporate both family andpsychosocial information into medicalcare. These family assessment toolsinclude the family APGAR, family circlemethod,2 genogram,3 PRACTICE,4 andFIRO5 models.

Physicians using a family systemsmedicine orientation have found thatcreating a diagram of a family's healthcare problems assists them in managingmany of their patients' health care con-cerns. Genograms have been comparedto more traditional medical tools, such asx-ray films and cardiograms, that helpfacilitate hypothesis generation, differen-tial diagnoses, and ultimately a manage-ment plan for the patient.6 "Thegenogram can be thought of as an x-rayofthe family... It gives the physician andthe patient a graphic display of the fam-ily, including the family's patterns of ill-ness and psychosocial problems."7

Construcing a genogramSymbols for genograms have been stan-dardized, enabling physicians to build a

282 Canadian Family Physician VOL 40: Februay 1994

I

picture of family structure quickly and seehow it affects a patient's ability to copewith illness or other significant life stres-sors (Figure 1).6 A genogram collects andrecords three generations of family infor-mation in six specific categories:* family structure;* life cycle stage;* pattern repetition across generations;* life events and family functioning;* relationship patterns and triangles; and* family balance and imbalance.A8-0

Physicians wanting to adopt a family sys-tems orientation to patient care will oftenstart with a basic, or "skeletal," genogram.Completing a skeletal genogram with a newpatient is frequently an effective way todevelop baseline data on who the otherfamily members are, who lives at home,what this patient's context is, and what thefamily's patterns of illness are. The skeletalgenogram takes 5 to 20 minutes to completeand is limited to questions of family struc-ture, significant family events, and history offamily health problems. Often a skeletalgenogram can be completed while record-ing a traditional family history.

X~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~....

During the first visit with complex fam-ilies, a genogram is best limited to onlytwo generations, or to only family mem-bers with significant health problems.Missing family data can be added later ifnecessary. Family physicians should con-sider completing expanded genogramswhen confronted with patients or familieswith difficult clinical problems (Table 1).Expanded genograms focus on three-gen-erational relationship patterns and usuallytake 20 to 30 minutes to complete.3'7'9

BenefitsThe information recorded in genogramsassists family physicians to generatehypotheses about patients' risks for family-related illnesses or stressors, such as dia-betes, hypertension, coronary heartdisease, substance abuse, and depression.A family history of these problems oftenallows a family physician to generate ahypothesis about a patient's presentingcomplaint quickly and then develop ques-tions that help in coming to a diagnosisand management plan.6 For example, fora patient with gastric complaints, agenogram that indicates a strong family

Table 1. Issues for whichgenograms might behelpful

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

Canadian Family Physician VOL 40: Februagy 1994 283

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,after she was referred urgently by her

sister who worked as an emergency room

nurse at the local hospital. Her sister saidonly that she was having lots of stomachproblems and was under a lot of stress.When I met this 38-year-old woman, shelooked depressed and tired with slightlybloodshot eyes.

When asked why she was coming to see

me, she said somewhat angrily, "I've beento see three doctors so far and none ofthem could help me with this stomachproblem." I suspected at that point thatshe might be a difficult patient. She com-

plained of dyspepsia symptoms includingheartburn, bloating, and epigastric dis-comfort for the past 6 weeks. She had no

nocturnal pain or melena. She had triedantacids with no relief. When asked whatshe thought was causing her symptoms,she said she thought it might be an ulcer. Iasked her about alcohol intake and sheindicated that she had increased from twoto three drinks a day. She also stated thatshe smoked 20 cigarettes a day. At thispoint she became very impatient, sayingshe had to get back to work. As her

physical examination was normal,I prescribed an H2-receptor blocker andasked her to return in 2 weeks.When she returned I asked her whether

she had any stressors in her life. Sheacknowledged it had been difficult for herrecently. She also stated that her stomachfelt much better, and she seemed lessangry. I asked, "Do you think there couldbe a connection between your stomachproblems and some of the stresses in yourlife?" She then related how she had bro-ken up with her boyfriend 6 weeks ago

and had subsequently increased her alco-hol intake. She appeared upset about thisand seemed on the verge of tears. Shewent on to talk about how stressful herwork had been lately. With the informa-tion on excessive alcohol intake, dyspep-sia, and smoking coupled with a

demanding, stressed patient, I decided toconstruct a genogram to gain a betterunderstanding of family health issues andrelationships.

Nuala talked about her alcoholic father,whom she hated for constantly beratingher mother and herself. She denied any

physical or sexual abuse. She described

her mother as meek and passive. Bothparents died several years ago. "Well,Nuala," I said, "Sometimes these experi-

ences can affect us in ways that we don'tunderstand. It seems that people whohave lived in families like yours often havepains that doctors cannot completely fix.Perhaps your pain is somehow connectedto your past." I

"Could be," she said.I then completed her examination and

reviewed her blood test results, whichshowed a mild elevation of liver enzymes.I suggested that she would have to stop herexcessive alcohol intake if she ever wantedto get better. I mentioned some options fortreatment and suggested she return in3 weeks for a follow-up visit.On the third visit, she looked more at

ease and healthier. She said she hadthought a lot about what we discussed onthe last visit, especially with regard to herfamily. She recognized some patterns ofalcohol overuse, especially in her grand-parents, father, and brother. She thoughtthat she would seriously like to explorealcohol treatment programs and alsoobtain counseling for her stress problems.

284 Canadian Family Physician VOL 40: February 1994

Figure 2. NuaLaK.'. gpatrem: lpat cormpaind fsh.pnmb.

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 36imitedsupport jts l

(e& -family and friends); anda Patient's stomach problemns

were likely a combination ofher ncreased ol4 J|oand her intern Iizaon ofstress..

history of alcoholism would lead to a highindex of suspicion about the possible roleof alcohol. Genograms can also be effec-tive for evaluating the problems ofpatientswith multiple vague complaints.

By doing a genogram with Nuala(Figure 2), I was able to enhance our rap-port. Often demanding, difficult, and angrypatients, as well as patients whom physi-cians dislike, respond well to being involvedin completing their genograms. Thegenogram process frequently lets patientsand physicians escape from what feels likean unproductive relationship. Patientsinterpret the genogram process as an act ofbeing listened to and cared about as people.

The process permits physicians to learnmore about patients' life experiences, and asa result, to be more empathic to patients'needs and behaviours (Figure 3). The newinsight and empathy can in turn be used tofacilitate a more effective and satisfying doc-tor-patient relationship for both patient andphysician. The increased rapport oftenmeans patients are more open and acceptingof both medical and nonmedical referrals.

Completing a genogram also commu-nicates a message to a patient that a fami-ly physician is interested in addressingfamily and psychosocial problems as partofongoing health care. Many patients andphysicians find the genogram a nonthreat-ening way of inquiring about potentiallysensitive issues, such as sexual abuse andalcoholism.7"2

The visual impact of genograms canalso be useful for both physicians andpatients in determining whether presentingmedical problems are connected to familyor psychosocial issues. Family physicianscan quickly look at complex medical andrelational genograms and understand howfamily information could affect patients'presenting complaints. On the other hand,patients are often struck by recurring pat-terns in their families, such as alcoholismand cardiac problems. This informationcan influence patients' awareness, and fos-ter a sense of urgency to deal with andmake decisions about complying with sug-gested medical regimens (Table 28).9

Potential roadblocks to usinggenogramsThe main concern expressed by familyphysicians is the length of time it takes to

complete a genogram. Some family physi-cians consider genograms to be impracti-cal in a busy office practice because theyincrease the amount of time spent on thefamily history section of the office visit.'3Family physicians who have successfullyintegrated genograms into their practicesacknowledge that the genogram processincreases the length ofvisits. However, theyalso believe that the extra time required isoften well spent building patient rapport orproviding potentially useful family infor-mation that can be used to address apatient's concerns during a particularoffice visit or at some future visit.

It is also important to note that agenogram is rarely completed in one officevisit and is often constructed with a patientover tirne. For example, many physiciansconstruct a skeletal genogram when theyfirst meet a patient, and then expand itwhen indicated. Often, the genogram iskept in a special place in the chart(eg, attached to the back) so that it can beeasily located, and therefore referred toand built upon repeatedly.

The other criticism of genograms isthat, to date, research has not proven theclinical utility of this family assessmenttool.'0,'247 However, studies have shownthat the genogram process captures morepsychosocial and biomedical informationthan traditional history taking.'4"15 Theresults of these research studies should notdiscourage family physicians from usinggenograms (only 10% to 20% of interven-tions used in medicine are supported byrandomized control trials'8). Futuregenogram research should focus on exam-ining whether there is value in having agenogram as baseline information forevery patient's chart and what specificpatients, or particular patient problems,could benefit from genograms. 19

ConclusionA genogram is a practical clinical tool thatfosters a family systems approach topatient care. Genograms give familyphysicians a quick, integrated picture ofpatients' biomedical and psychosocial his-tories. Genograms allow family physiciansto diagnose and manage difficult biopsy-chosocial clinical problems that often cannot be addressed using the traditional bio-medical model. Genograms also assist

Table 2. Benefits ofgenograms

SYSTEMATIC MEDICAL RECORD KEEPING* Easily read, graphic format* Identifies generational,

biomedical, andpsychosocial patterns

* Assesses connectionsbetween family context andillness

RAPPORT BUILDING* Nonthreatening way to

obtain emotionally ladeninformation

* Increases trust and patientcompliance

* Demonstrates interest inpatient and significantothers

* Reframes presentingproblem for patients

MEDICAL MANAGEMENT ANDPREVENTIVE MEDICINE* Highlights supports and

obstacles to compliance* Identifies life events that

could affect diagnosis andmanagement

* Identifies illness patterns;facilitates patient education

Adaptedfrom McGoldrick.8

Cnadian Family Physician VOL 40: Febmagy 1994 285

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

Peter T. was a 28-year-old marriedman of Portuguese descent who had

been a patient of mine for about 2 years.

My previous contact with him had beenminimal, consisting of an annual physicalexamination and a couple ofvisits regard-ing minor infections.When Peter came to see me at the clin-

ic, he was obviously agitated and dis-tressed. He reported that he had beenhaving some chest pain associated withdyspnea during the past 10 days, and thathe had had to leave work and go homeearly on a couple of occasions. As Petertalked about this, he was extremely anxiousand shaky. When I asked him what hethought was going on, he initially said, "Idon't know; that's why I came to see you."However as I persisted in trying to under-stand his concerns and fears, he indicatedthat he was worried that he might havesome problem with his heart.

While I did a physical examination, Iinquired about the various risk factorsassociated with heart disease, and discov-ered only one factor in his case (ie, hisfather had been diagnosed with anginaabout 4 years earlier). The examinationrevealed minimal tenderness along the leftparasternal region with no other positivefindings. I ordered a chest x-ray examina-tion and did a cardiogram in the office(which was normal).

Because I wondered whether Peter'ssymptoms were related to stress, I inquiredabout any recent changes or pressure in hislife. He told me of significant changes inhis work situation: some of his senior

colleagues had left the company a monthago to establish their own business, andthey wanted him to join them. He hadbeen ambivalent about this, but finallydecided to remain with his company.

Consequently he now had a more seniorposition with his company and felt thatexpectations ofhim were higher.

I established a working diagnosis ofcos-tochondritis, prescribed some coatedaspirin, and suggested that Peter return tothe clinic in 1 week. Three days after theinitial visit Peter phoned me in a very agi-tated state, saying that his symptoms hadnot improved at all and that he in fact hadto leave work early that day due to hischest pain. I tried to reassure him bytelling him that his chest x-ray examina-tion results were normal and that therewere no indications ofany serious physicalhealth problems.When Peter came in for a follow-up

appointment, he was again very anxiousand reported no significant change in hispresenting problems. I explained to Peterthat often many factors contribute tosymptoms such as his, and that to under-stand these more clearly I needed toobtain more information.

I proceeded to construct his familygenogram (Figure 3). As I asked Peterquestions about his own family, hisresponses were quite matter-of-fact; how-ever, in contrast, he was cautious andapprehensive when talking about hiswife's family. When I commented on thisobservation, he indicated in a sad tonethat it was difficult for him to talk about it.

When I suggested that often the most dif-ficult things to discuss are the mostimportant ones to talk about, he becametearful and began to express how muchhe missed his wife's mother.

She had died the previous year after a

yearlong battle with cancer. Peter statedthat he was very close to her and in fact,"she was more like a mother to me." Aswe discussed this further, it became appar-ent that Peter's grief regarding this losswas unresolved, as he had tried to remainstrong for his wife and her family at thetime of the death. In addition, Peter andhis wife took on increased responsibilitiesfor the extended family after this death,demands that were difficult and anxiety-provoking for them.When I asked Peter if there were any

similarities or parallels between that situa-tion and the recent changes at his work-place, he was able to identify that in bothsituations he had lost people about whomhe had cared and on whom he haddepended. I also indicated to Peter that hewas likely experiencing an anniversaryreaction to his mother-in-law's death,which was a normal and healthy part ofhis grieving process.

I explained to Peter that unresolvedgrief and other stressors in his life, com-bined with his anniversary reaction, were

likely the primary factors contributing tohis current symptoms. I suggested referralto a social worker for counseling, andPeter accepted this saying, "Talking aboutthese things with you today has helped meto see that they still bother me."

286 Canadian Family Physician VOL 40: Febmuary 1994

Ftgur 3. Peter T.'s genogram The patient complain ofcestpain.

_Iuiwi sht hP eterT.'s ,--_I6UF~~~A U6E AM 52 ~ WHACfI.50. Im

* Patient's relationship CAwith his mother-in-law;

* Patient's unresolvedgrief after the deatliof mother-in-law-,(anniversary reaction);and

* Patient's somatizationas a response to lossesand stressors.

I . .,|.".S!!...................T..... . ., . , .. -. ... ... ..... ,. , - ........~~~~~~~~~~~~~~~~~~~~~~~~100

physicians to establish rapport withpatients and to have empathy with, andunderstanding of, patients' circum-stances, especially when dealing withdifficult patients. U

Requests for reprints to: Mr I. Waters,Family Practice Unit, Groundfloor Eaton G-447,The Toronto Hospital, 200 Elizabeth St, Toronto,ON M5G2C4

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19. CampllrIT. Researclh relports: familyinterventions in faamily prac(tice. Fain SystemsMed 1992;10(2):227-9.

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