Family Medicine Tools

• Knowledge of patients and their families is good public relations.
• Efficient and responsible way to provide healthcare.

Tools for Assessing Families in Primary Care

• Family genogram/anatomy
• Ecomap
• Family circle
• Family life cycle
• Family life spiral
• Family APGAR
• Family timeline
• Family conferencing
• Others

• A genogram summarizes on one page a large amount of information relating to a family.
• It includes family hereditary background and accompanying risks, major medical, social, and interactional influences.
• The family genogram is also referred to as the family pedigree, family tree, family anatomy, or genealogic chart.

Value to Doctor, Family, and Patient

• Continuing care to the patient and family members.
• A systematic method of recording important information.
• Easy summary of the patient’s context. A picture is more than a thousand words.
• Identification of organic, psychosocial, and interpersonal problems.
• Aid to the explanation of the origin of symptoms to patients.
• A therapeutic tool for the patient and family.
• A preventive tool by highlighting health risks in older generations.
• Identification of complex family problems requiring referral to counselors/family therapists.

Drawing a Genogram

• Biodata: Names, age (DOB), marital status, former marriages, occupation.
• Social Relations: Children, marriages (date), households.
• Medical: Illnesses, dates of traumatic events and deaths (age, date, cause).
• Psychosocial: Emotional closeness/distance, family conflicts, divorce (date).

Note: Include information for at least three generations.

Genogram Layout Guidelines

• Title
• The firstborn members of each genogram are the farthest to the left, with siblings following to the right in order of birth.
• The standard family genogram chart consists of three or more generations, representing all members of both spouses’ families.
• It is traditional to place the husband’s symbol on the left.
• A single generation is represented on the same line, and symbols should all be the same size.
• The children of the first generation are indicated on the next generation line; in later generations, the first pregnancy (or child) is placed on the left.
• The family name is placed above each major family unit, and the given names are placed below each symbol.

• It can take an average of 15 minutes to complete a genogram, especially when patients are new to the practice.
• It is not compulsory to complete the genogram in one visit.
• The process helps build rapport and enhances the doctor-patient relationship.

Genogram May Reveal

• Transgenerational family patterns of loss (separation, divorce, death).
• Dysfunctional emotional patterns (substance abuse, domestic violence, etc).
• Common medical problems (asthma, hypertension, diabetes mellitus).

• Diagrammatically assesses the larger system within which the family operates.
• Family/household is placed in the center of the map.
• Around are other circles for parts of the larger system.
• Connections are drawn between the systems and the household by the use of lines to show strong, weak, or stressful connections.
• These connections can be described by texts.

• It is a circle to illustrate the emotional relationships of a family as depicted by one member.
• The size of the circle indicates importance.
• The distance from others reflects the degree of emotional attachment or closeness.

• Significant others, including friends and pets, also may be included if the person feels they are part of the family.
• The date is very important because these relationships almost always will change over time.
• The family circle is quick to complete and can be a rich source of information regarding family dynamics as well as a focus of opportunity for discussing family problems (Thrower et al).
• The family circle is among the most value-free, non-judgmental methods for discussing emotional and relationship problems without focusing on individual pathology (Thrower et al).
• It can complement the genogram and add useful information about family dynamics.

• Just as an individual can be described in terms of his/her stage in the human life cycle, it is possible to describe stages that occur throughout the life of a family unit.
• This conceptualization helps the physician assess a family’s functioning on a broader context and better understand the family’s strength and problems.
• It identifies stages of family development that reflect the biological functions of raising children.
• It differs based on family type, structure, functioning, culture, or ethnicity.

Stages of the Family Life Cycle

1. Family Formation
2. Childbearing Families
3. Family with Preschool-Age Children (Oldest Child < 6 years)
4. Family with School-Age Children (Oldest Child 6 - < 13 years)
5. Family with Teenage Children (Oldest Child 13 - 18 years)
6. Family Dispersion (Oldest Child 18 years+)
7. Older Couple

• It is a nonlinear representation of family development - Family members move together in development.
• The spiral includes the developmental tasks of three generations that simultaneously affect one another.
• Each person's developmental issues can be seen in relation to those of the other family members.
• For example, midlife crisis of adults in the middle years of their lives such as parents' plans for retirement may coincide with their adolescent children's identity struggles.
• Individual life cycles of each family member intertwine with the life cycle of other family members in a family life spiral.

Family Life Spiral Characteristics (Combrinckn – Graham)

• Centripetal Relationship
• Forces pulling families together.
• Illness of infant draws on centripetal forces for care.
• Centrifugal Relationship
• Forces moving family members apart.
• Adolescent with diabetes requires balance between independence/autonomy and care by parents.

Not the Apgar in Neonatology

To assess a family member’s perception of family functioning by examining his/her satisfaction with family relationships.

Family Apgar

The measure consists of five parameters of family functioning:

• Adaptability,
• Partnership,
• Growth,
• Affection, and
• Resolve.

The response options were designed to describe the frequency of feeling satisfied with each parameter on a 3-point scale ranging from 0 (hardly ever) to 2 (almost always).

FAMILY APGAR
PARAMETER	SCORE
	Hardly Ever	Some of the Time	Almost Always
ADAPTABILITY	0	1	2
I am satisfied that I can turn to my family for help when something is troubling me.
PARTNERSHIP	0	1	2
I am satisfied with the way my family talks over things and shares problems with me.
GROWTH	0	1	2
I am satisfied that my family accepts and supports my wishes to take on new activities or directions.
AFFECTION	0	1	2
I am satisfied with the way my family expresses affection and responds to my emotions such as anger, sorrow or love.
RESOLVE	0	1	2
I am satisfied with the way my family and I share time together.

7 – 10: Highly functional family.

4 – 6: Moderately dysfunctional family.

0 – 3: Severely dysfunctional family.

In Chao's study, poorer family satisfaction was highly correlated with:

• poorer individual spirits,
• greater degree of recent individual stress,
• poorer subjective rating of health,
• greater number of clinic visits, and
• increased number of missed appointments.

Timeline presupposes that certain illnesses are based on events and the period they occur. For example, in a patient who has somatic symptoms of 3 years duration, it may be possible to discover that he had a major life event at about the same time.

Home visits or house calls are on the increase due to the growing need resulting from shortened hospital stays and increased home care involving intravenous fluids and chemotherapy. Family Physicians use house calls to develop a thorough understanding of their patients and their environment. Family Practice residencies also encourage house calls in their training programs.

House Calls

Types (Described by Cauthen 1981)

1. The emergency home visit/house call.
2. The acute illness home visit/house call.
3. The chronic illness home visit/house call.
4. The dying patient home visit/house call.
5. The home visit/house call to pronounce death.
6. The grief home visit/house call.
7. The home management-versus hospitalization house call.
8. The home visit house call.

Definition: A specially convened meeting of key family members with specific goals.

Family conferences can be arranged at the request of the Physician, the patient, or the patient’s family members to discuss the patient’s health problem or other family problems in more depth than a routine visit can permit.

Characteristics:

• Complex to set up
• Least common of the types of family interviews
• Important tool in family-oriented care
• Focus of most literature on family interviewing
• Well accepted by patients

• Medical Informatics: Utilizing information technology for managing and organizing medical information.
• Telemedicine: Providing healthcare services remotely using telecommunication technologies.
• SCREEM: A family assessment tool representing Social, Cultural, Religious, Economic, and Medical factors.
• etc