Family Genogram in General Medicine: A Soft Technology that can be Strong. An Update

What is traditionally called individual, family and community care are elements of the same reality and cannot be separated. The genogram is an instrument or tool of the biopsychosocial model that gives information about the patient, their family and context, and that implies a prognostic value and useful information for the consultation. The biomedical family history means collecting problems of genetic transmission, but from the biopsychosocial point of view it can go much further: the elaboration of the genogram produces a therapeutic link with the family, implying a qualitative change in the relationship; the genogram gives rise hypotheses - in circular terms- about patients’ risks for family related illnesses or stressors, such as diabetes, hypertension, coronary heart disease, substance abuse, and depression; It allows developing a provisional explanation about how the family system is organized around a problem; genogram shows events of family life, transitions and turning points, that mean opportunistic prevention and treatment moments. “Complex” genograms present families with psychosocial problems that can be expressed like biomedical problems. The genogram can be used as a screening system in all patients, at their first glance, regardless of the problem that motivates their consultation, to identify biological or psychosocial problems that would manifest themselves later. It is advisable to make “feasible” genograms avoiding excessive information that paralyzes understanding and intervention. The genograms are a fixed photograph of the family at a certain moment, and the concept of “chronogram” should be incorporated (evolution of the same genogram after the time).


Introduction
Why take into account the family in general medicine? Most of the work of the family doctor occurs with individuals; but this is only a simplification of the importance of the factors that surround the individual. Nobody discusses theoretically and conceptually the important role played by the family in the health and well-being of its members, but in everyday medical practice the family is a frequently forgotten or only partially considered element; thus, when thinking about assistance or health care, there is a tendency to conceive it as an individual situation [1].
However, whether or not a person belongs to a family group, their previous family experiences will be significant. The family has a lasting impact on the development of the personality; the family forms the personality, attitudes, behaviors and beliefs of the child. Although a person can change during their life, the influence of the family cannot be completely avoided. The family can be seen as a system in which the total is greater than the sum of its parts. Each person contributes as a unique part to the system, but is also affected by the relationships with the other members. The family unit plays an important role in providing "care" to all its members. The disease that affects an individual can seriously affect the family unit, and on the contrary, the family unit influences the health of the individual members. An individual's problems are usually best understood when placed in the context of the family. Problems are often shared by more than one individual in the family, and the family itself may hold the key to successful solutions [2][3][4][5].
Families play an essential role in the health and illness of people. Family support affects the results of numerous health problems. The disease usually occurs at times of family crisis. It is common for the general practitioner to be consulted by the family about the diagnosis and treatment plans of a member of the same. Once the family doctor is attentive to the family and their internal relationships, he can invite the family to participate in solving the problem, using listening and participation skills.
What is traditionally called individual, family and community care are elements of the same reality and cannot be separated: that is, there is no individual care, but it is always at the same time familiar and communal. The doctor-patient relationship is actually triangular: doctor-patient-family. General Practitioner must count on the family as a primary element for treatment (hygienic measures, diets, taking drugs, exercise, rest ...) [6].

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Res Med Eng Sci context in the care process. This implies considering and including the family in the care process. The family group must be identified as a possible patient or client, not only as the context in the care of the individual patient. This approach implies conceiving the family as a system, in which a special, close and lasting interaction takes place between the components. Various techniques or technologies or instruments can be used to assess and characterize the family function in the general practice . Among them, one of the most useful is the genogram [7][8][9].

How are the genogram technology / tool?
The genogram is a schematic model of the structure and processes of a family. The genogram is an instrument that allows us to easily incorporate and retrieve information about the family in which the patient is immersed, as well as to analyze and better understand that information in order to achieve a better resolution of their problems. There are several conventional signs that represent the various structures, functions, etc. Figure 1-3 show some examples [10][11][12]. Alternatively, it could be "invented", individually, a system of simple signs that, to a specific general practitioner, allow him to know data that he considers that could have special importance at the time of knowing causes of health and disease in the family of his patient and to use that data for him later benefit; for example, to collect non-habitual categories such as health beliefs in that family, level of family self-esteem, relational capital of the members of that family, etc.  The genograms are formats to draw a family tree and thus have information about it quickly and clearly. Genograms are subjective interpretive tools with which hypotheses can be generated for other systematic evaluations (for example, the place a person occupies in the group, the differences in age and sex, dysfunctions ...). It also gives us dates that indicate critical events in the family that have a strong impact on its functioning [9,[13][14][15].
Genograms can include members of the nuclear family and the annexes of that family, members who lived with it (brothers-in-law, cousins, grandparents, etc.) with an important role in it, and give us a summary of the family situation, their problems and relevant events (critical events in that family, for example, a suicide, an accident, an important work problem, a change of population due to a critical situation, etc.); also demographic facts (dates of births, deaths, marriages, separations), place of origin, and functional information (cultural level, employment status). With the different structural configurations of the family that appear in the genogram, General Practitioner can try to predict characteristics of personality and relationships, as well as patterns of functioning, relationships and structures that continue or are altered from one generation to another (interpretation horizontal and vertical).

Genogram may reflect:
A. Family

How is the genogram technology applied?
Naturally, the interview with the purpose of constructing the genogram must go from the concrete and punctual to the general and extensive within the family system. In addition, the elaboration of the genogram produces a therapeutic link with the family. When the doctor constructs the genogram, he finds a drawing that modifies the traditional relationship with his patient, since he has in front of him, a large amount of information that refers both to the patient and his family. The realization of a genogram always implies a qualitative change in the relationship with the patient. The genogram information can be obtained by interviewing one or several family members (which occurs naturally in the general practice consultation over time, when several family members are attended, or some of them come accompanied by others, etc.) [22][23][24][25][26][27].
On the other hand, the genogram gives rise to work hypotheses: hypotheses about patients' risks for family related 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. Genogram allows developing a provisional explanation about how the family system is organized around a problem; linear or "common sense" hypotheses of cause and effect should be avoided; on the contrary, they must be systemic hypotheses with relationships in circular terms, covering three or more elements. The hypothesis must, however, be simple and based on the phase of the life cycle that the family goes through, on the genogram data and on the opinions expressed on the problem, emotional tone, involvement of each member, etc. The hypothesis creates the thread of the interview, avoiding the disorder and the loss of information [28][29][30][31].
What can the general practitioner perceive at the first glance at the genogram? The genogram is a family map that allows you to have an aerial view of family history. A look at the structure of the genogram usually shows the composition of the family, that is, whether it is an intact nuclear family, a family with one parent only, a family that remarried a family of three, etc. When doctor watch genogram, sometimes, certain structural configurations can suggest him critical issues for the family. For example, he can observe many separations and / or divorces, frequency of adopting children, etc. But surely what is first perceived is that it is or it is not a "complex" genogram. An almost immediate visual evaluation, based on the intuitive criteria allows doctor to understand the genogram: the structure of a family, the relationships between the members of a family, registration of the most significant data; and the details, signs, well-defined shape, vague shape, etc., gives general practitioner the impression of complexity or simplicity. A "mythical" example can be found in the Oedipus family, the Greek king of Thebes. Oedipus

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accidentally fulfilled to prophecy that would end up killing his father and marrying his mother, bringing disaster to his city and family [32,33] (Figure 4).
Genograms with complex family patterns are a risk factor for the frequent use of primary care: the general practitioner, with a glance at the genogram of the clinical record, can predict whether this patient is a "difficult" or complicated patient to attend, and if he will consult frequently. And if that patient is "interesting" from the biopsychosocial point of view, and that the genogram can provide useful information for contextual understanding and intervention. The subjective assessment of the genogram at first glance by the doctor, gives clues not only about the family represented in it, but it is a kind of Rorschach test that gives information on the personality of the doctor or his theoretical framework of work [20,34]. Thus, the genogram can be used as a screening system in all patients, at their first glance, regardless of the problem that motivates their consultation. It is thought that performing the genogram in all people who come to the consultation for the first time could serve to identify biological or psychosocial risk factors of processes that would manifest themselves later and also to detect emotional problems [35].

What can the general practitioner perceive when comparing genograms of different dates, perhaps separated several years from each other?
The general practitioner, by comparing genograms from different chronological times, can appreciate a "timeline" in the family. The interpretation of the genogram can be done horizontally (life cycle) and vertically (through generations). At the horizontal level, interpretation arises from the tensions that weigh on the family as it moves through time, enduring the inevitable changes, misfortunes and transitions in the family's life cycle. At a vertical level, interpretation derives from patterns of relationship and functioning that are transmitted historically from one generation to another, especially through the emotional triangle process. The genogram gives information on the family life cycle, and consequently is a useful tool for continuity of care. The genograms are a fixed photograph of the family at a certain moment, and the concept of "chronogram" (evolution of the same genogram over time) or "line of time or life" should be incorporated. It is common for family patterns of "functioning" and "relationship" to intensify when a structure repeats itself from one generation to the next. When we seek a repetition in the functioning and relationships, we also seek the repetition of the family structure. In the successive visits over time it is an invaluable help to learn about the evolution of the problems of other members of the family and to handle them globally [36][37][38].

In what sense does genogram technology help general practitioner to make decisions?
Genograms show the structure of the family, and the relationships between the members of a family. The contributions of the genogram and its interpretation will depend on the type of clinical decision that we should take in the following three levels [19,39,40]: a. In prevention it can help us find out diseases, both known genetic transmission (diabetes mellitus, thalassemia), and infectious, and psychosocial disorders (alcoholism, depression) which have a tendency to repeat in the family. Depression in a family member is associated with an increased incidence of psychopathology and physical morbidity in other members. Having this in mind can facilitate prevention, early diagnosis and adjust the advice to the stage of individual or family development in which the patient or family is located [41][42][43][44]. Figure 5 shows an example of an outbreak of conjunctivitis in a family [41]. b. In the diagnosis it will help us in carrying out an analysis from the biopsychosocial point of view, that is, a systemic hypothesis of the demand. So we can assess how family history may be influencing your current illness and what health beliefs the patient and family may have [45][46][47].
c. In the treatment it will guide us in those family factors that will facilitate or complicate a particular treatment and the family support that will have at the time of doing it. Interactions within the family show a triangle. Most interactions within the family involve two people. When stress occurs in this dyad, there is a natural tendency to involve a third person. The role of this third person is to "rescue" the pair. Stress is reduced, and the focus of the problem deviates from the dyad to this rescue person. When a person feels hurt, angry, disappointed or frustrated with another family member, and cannot face this situation with him, he tends to put another member in the relationship. Parents often use their children to do what they do not do to each other. Children also involve their parents in triangles for relationships with one another. Sometimes another family member or friend enters the triangles. Since triangulation seems to reduce stress, family members repeat this strategy trying to maintain control and family unity. But triangles are ineffective coping mechanisms, since stress is not permanently reduced, and generally have problematic consequences [48][49][50][51]. The genogram shows us the events of family life and functioning (stressful life events that may be causing crises and family dysfunctions), that is transitions and turning points, which general practitioner can do opportunistic prevention and treatment [52][53][54][55][56][57][58].

Conclusion
A basic premise of the biopsychosocial model is that the impact on a subsystem -biological, individual, family, community -affects the rest, both in health and disease [59]. There is an important body of knowledge based on well-designed and randomized studies that show that the family has an important influence on health: in asthma, cardiovascular disease, hypertension, obesity, mental health, infections, medical visits and hospital admissions, etc. When the greater the complexity of the problem to be addressed, also is the greater the need to work with the family group. The conception of the family as a system helps to understand individual symptoms that may play a role in family dynamics. The persistence of the symptoms can indicate a difficulty of the family to adapt to a certain situation of change or to solve a determined conflict.
Among the practical instruments to apply the biopsychosocial model in the consultation is the genogram. Genograms show family information in a way that allows for a quick look at complex family patterns and is a rich source of hypotheses about how a clinical problem may be connected to the family context and the evolution of the problem and context over time. It provides a view of the family structure and relationships between family members as a photograph [60].
The genogram is a simple and practical recording instrument whose use allows the health care provider to store a large amount of information on clinical and relational aspects of a family, with data from several generations. It should be understood that "complex" genograms present families with psychosocial problems, both in their personal lives or in interactions with the healthcare system with the appearance of biomedical problems (frequent consultants, non-compliers, "difficult" patients) [61].
Jumping from the individual sphere to interpretations of symptoms and problems from a relational perspective is not easy, but it can mean the breaking of a vicious circle and initiate a different approach, a change of frame in which interventions not focused on the symptom even in the organic field. Frequently general practitioners, especially when they have a long relationship with their patients, come to take this step casually with some of them or even consciously provoke it intuitively.
But, how can we organize the almost unlimited data that can be collected from families? What do we need to know about the family in terms of health? It depends on the use that we think to make with that information. Part of the problem is that we can easily have too much data at our disposal. Organizing these data and placing practical limits on our research is fundamental. Drawing a genogram should be "feasible" [62]: instead of making a multigenerational detailed history, use a few questions as a check, and if key issues are identified, decide if more evaluation is needed. That is, general practitioner should collect useful data for medical management. In any case, with the genogram, the general practitioner has at his disposal a "soft" technology that gives "strong" results. The soft wins to the hard [63,64].