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Virtually every doctor will have learnt at medical school how to draw a genogram. Genograms (sometimes spelled geneograms but always pronounced ‘gene-o-grams’) are basically family trees, but annotated with further relevant information according to the clinical context. In some specialties like clinical genetics or haematology, they are used routinely to record which members of a patient’s family carry a particular gene or suffer from an expressed inherited disorder. In specialties like family medicine,1 paediatrics,2 palliative care3 or psychiatry,4 they are usually taken in order to gain a more informed understanding of a patient’s personal circumstances and the background to their presentations. Indeed, some practitioners in these fields regard genograms as an indispensable tool for understanding family systems and dynamics, or even for just remembering details like everyone’s names and ages. Over many years as a general practitioner (GP) I kept folders containing the genograms of most of the patients I looked after. I shared a belief with many of my colleagues that drawing a genogram is not only one of the best ways of gathering essential personal information, but also a good way to demonstrate human curiosity, build a relationship of trust, and enter more fully into people’s personal and illness narratives.5
There is a simple system of notation in genograms to show such things as gender, and whether a relative is alive or has died. There is also a straightforward way of linking different individuals together to show their relationships as parents and children, along with first or subsequent marriages, divorces and so forth (see figure 1). Additional information can then be added according to the needs of the clinical situation. This can include the years of births and deaths, and other brief biographical information that seems important – like occupations, place of residence, languages spoken, or role as a carer. Such details can be important, for instance. in understanding who might need to be mobilised to support a frail elderly person returning to the community. In specialised areas like child psychiatry and family therapy, there are a variety of other recognised symbols for marking such details as conflictual relationships, but these should probably be used sparingly, since they may only represent one person’s perspective, and they could be seen as intrusive or judgemental.
Quick and efficient method
There is a common perception that drawing genograms is time-consuming. In reality, setting down essential information in the form of symbols is actually a quicker and more efficient than using words, especially if you do it regularly. You can also pack more information into a small diagram than through writing and, as a visual aid, it is far easier to use than reading through prose. If necessary, you can jot down some core details in less than a minute on the first occasion you meet someone, and then extend the diagram during subsequent conversations by adding one or two more generations and further annotation.
An even more unhelpful misconception is that genograms are just about recording facts. Although in many instances this is a necessary function – for example, to record that a child’s parents are divorced, or that an elderly person’s only child lives far away – in most situations taking down a genogram is more of a shared creative act. This is especially the case if you draw it sitting alongside the patient, rather than opposite them. When patients narrate the objective facts of their lives, they have an opportunity to share their emotions too, perhaps when they are speaking about transitions such as births and bereavements, relocations or migrations, and other causes for celebration or grief. While doing so, they may well make new connections in their minds – for example, when they see a pattern of illness, separation, social mobility or mutual support emerge among many individuals or more than one generation. Your own sense of affiliation with them as a professional is likely to increase. If done sensitively and with clear consent and the right timing, drawing a genogram brings practitioner and patient closer to each other, and creates mutual respect.
Some physicians and surgeons still appear to think that genograms are a specialised form of intervention, best reserved for complex psychosocial problems and only done by mental health professionals with special training or resources to deal with these. In reality, it is hard to think of any medical or surgical cases, except the most trivial ones, where it would not be useful to have a sketch of someone’s immediate support network to hand. Just as I found it beneficial to have folders of genograms readily accessible in my own GP practice, there are obvious advantages to having these available in a regular format, and in a predictable place, in people’s hospital records. I would certainly encourage any junior doctor to consider doing this as a routine, and hope that many teachers might want to teach and model it as a key skill for the clinic or ward.
Finally, I can highly recommend compiling your own genogram. It can be one of the most enlightening exercises in personal learning that you ever carry out. Although you can easily do this on your own, it is more powerful if you do it in the presence of a friend or colleague who can afterwards repeat the exercise the other way around, with yourself as interlocutor. (Even if you have done this before, you will almost certainly recall new details or establish new understanding each time.) If you start out with just the details of your immediate family – parents, siblings, plus partner and children if you have them –you will find how easy genograms are to draw, merely by using the basic symbols and people’s names. Then, by adding in more relatives or generations and further information of your choice as you go along you will see how much crucial information can be included on a single page. If you want to make the exercise more imaginative, try looking at patterns like the first names people in your family were given in each generation and why, where people lived as adults in relation to where they were brought up, and what jobs they did compared with their parents. You may experience exactly the same kind of insights that your patients will often do in these circumstances – and you may discover that sharing a genogram, or even a small part of it, is a profoundly humanising activity for everyone involved.
Twitter Follow John Launer @JohnLauner
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.