Using Practice Genograms To Understand And Describe ... - STFM

490 July-August 1998 Family Medicine
Using Practice Genograms to Understand
and Describe Practice Configurations
Helen McIlvain, PhD; Benjamin Crabtree, PhD; Jim Medder, MD, MPH;
Kurt C. Stange, MD, PhD; William L. Miller MD, MA
Background: Demands for change in medical practices are coming from multiple sources. Since
interventions to change clinical practice continue to have limited success, understanding the functional
structure of primary care practices and the dynamics of providing care have become increasingly
important. Methods: To portray and understand the primary care office system, we developed
“practice genograms” that describe practice participants and their relationships with each other.
Formal organizational structure is evaluated using family systems theory and family of origin
genogram techniques. Results: Practice genograms provided a more dynamic, relational model than
the organizational chart and promoted identification of relationship strengths and weaknesses
within a practice the same way that family genograms identify these characteristics in a family
system. Conclusions: Research implications for the use of the practice genogram include enhanced
data gathering, increased understanding of the complexity of practices as adaptive systems, and
increased understanding of current and potential approaches to changing practices.
(Fam Med 1998;30(7):490-6.)
Facilitating change in clinical behavior is not always
successful. 1-5 Yet, with the proliferation of clinical
practice guidelines, the decrease in numbers of small,
independent practices, and the growth of managed
care, physicians are under pressure to change and
adjust to change. Unfortunately, “one size fits all”
interventions to facilitate change often don’t have
long-term effects because physicians and their practices,
while seeming similar, are each unique in practice
behavior, motivation, and office culture. 6-9 Recent
literature suggests that it may be effective to use
systems theory models in which primary care practices
are viewed as complex adaptive systems. 10-11
However, little research has been done on systems
models of change in clinical settings, and, therefore,
tools to assess primary care practices are lacking. We
developed such a tool, loosely based on the family
genogram, 12 a technique with which most residency-
From the Department of Family Medicine, University of Nebraska Medical
Center, Omaha (Drs McIlvain, Crabtree, and Medder), the Department
of Family Medicine, Case Western Reserve University, Cleveland,
Ohio (Dr Stange), and the Department of Family Medicine, Lehigh Valley
Hospital, Allentown, Pa (Dr Miller).
trained family physicians are familiar. We created a
“practice genogram” that allows researchers to understand
practice behaviors and relationships in the same
way that a family genogram promotes understanding of
family dynamics. This paper defines the practice
genogram, describes data-gathering methods, gives a
case example, and discusses implications for use.
Family Genograms and Practice Genograms
Systems theorists propose that individual actions
by one part of a system can only be understood within
the context of the entire system, since all individual
actions are influenced by the functioning of the system
as a whole. 13 Problems are assumed to reflect a
system’s adaptation to its total context.
The family genogram is an assessment tool used
to identify patterns of family interaction and provide
insights about system strengths and vulnerabilities. 12
The genogram provides a visual “gestalt” of complex
family patterns that is used to generate tentative hypotheses
about the way in which problem behavior
functions within the family context. 12,14,15 These hypotheses,
if validated, may then suggest opportunities/avenues
for positive change within a family
system. The genogram has been adapted by family
physicians as a tool to operationalize a family-cen-

Educational Research and Methods
tered biopsychosocial approach to care. 16 Particular
emphasis is placed on emotional connections among
family members, across generations, and with important
individuals or systems outside of the family system.
Constructing a genogram involves three activities:
1) visually mapping the structure of a family, 2)
recording important information, ie, demographics,
critical events, and crucial issues, and 3) showing
emotional relationships and informal roles among
members of the family.
Increasingly, organizations are being viewed as
complex, adaptive systems “that are conscious entities,
possessing many of the properties of living systems.”
17 The commonly used “machine” metaphor
that emphasizes structure and parts is no longer adequate.
Instead, organizations are now studied as
“whole” systems, especially when considering
change. 10 As family therapists discovered with families,
to comprehend fully the “gestalt”of an organizational
system, it is helpful to visualize the organization
in terms of its complex relationships.
Organizational charts can be used to understand
how a practice functions; however, they are more
likely to indicate how things are supposed to be than
how they really are. Organizational charts rarely identify
the informal, emotional, and relational patterns
that are obvious to anyone who has ever worked in
an organization. Genograms give that information,
expanding a basic organizational chart into a more
useful tool. It seemed a reasonable extension for us
to use this tool to understand the organizational dynamics
that could promote or prevent the implementation
of change at the practice level. In constructing
our practice genograms, we use similar concepts and
terminology (Figure 1) to those used by McGoldrick
and Gerson. 12
Development of the Practice Genogram
Since 1994, researchers in the departments of family
medicine at the University of Nebraska Medical
Center (UNMC) and Case Western Reserve University
(CWRU) have been collaborating in the analysis
of preventive service data from 82 primary care practices
in northern Ohio. 18 Concurrently, UNMC researchers
were initiating an intervention study in eight
Nebraska family practices using the Put Prevention
into Practice materials. 7 In the process of assessing
those eight practices, one of the authors started informally
using the genogram technique to keep track of
the individuals involved in the practices and their formal
and informal relationships to one another. This
helped us understand the strengths and weaknesses
of each system relative to the intervention. Although
not formally used in all 82 Ohio practices, our knowledge
of these practices provided an opportunity for
discussion and expansion of the genogram concept.
We currently have experience using the practice
genogram in 59 locations, ranging from simply de-
Figure 1
Vol. 30, No. 7
Symbols Used in Practice Genograms
491
scribing some practices to interventional changes in
others. These experiences are described in more depth
as follows.
The Nebraska Experience: Practice Genograms
Through Participant Observation
The UNMC experience was designed to provide
detailed descriptions of practices to understand their
processes for providing preventive care. We used a
case study framework employing a multi-method ethnographic
data collection approach. 19-21 Research sites
were told that we would like to study their practices
and delivery of preventive services to better understand
the barriers and facilitators to providing preventive
care in real-life practices. Methods of data
collection and analysis, including the genogram, were
discussed prior to the practice agreeing to participate.
Practices were told that they would be given a summary
of their prevention practices, including the
genogram, at the end of the analysis.
Primary data were participant observation field
notes, 22-24 key informant interviews, 25,26 in-depth interviews
of physicians and office staff, 27,28 documents
used in the practice, 29 and medical record reviews. A
research nurse collected these data as she observed
practice activities. Observational field notes and key
informant interviews were the primary data used to
understand behavioral patterns within the practices.
Field jottings (short reminders) taken during observation
and clinical encounters were later expanded
into more extensive field notes describing the research

492 July-August 1998 Family Medicine
nurse’s impressions of the practice.
Informal, unstructured key
informant interviews with office
personnel were undertaken to
clarify observations. By reading
the notes, the investigators got
a sense of the practice before
working with the research nurse
to construct the genogram.
Once the research nurse was
in the practice long enough to
understand the basic practice environment,
the research team
interviewed her to construct the
genogram. We found that a
large, easily erased white board
is the best place to work on initial
drafts of genograms. The
organizational chart format was
used, starting with the assumed
hierarchy of authority and responsibility
that would be expected
with a given set of related
roles (Figure 2). The research
nurse was asked to identify all
participants in the practice and
their roles. Demographics of the
Figure 2
Practice Genogram Formatted in Organizational Chart Format
Figure 3
Practice Genogram With Relationships and Footnotes Obtained After 2 Days of Practice Observation
FOOTNOTES:
1. “Bee in bonnet” about prevention—
wants to make changes

Educational Research and Methods
individual members were elicited, including age, gender,
number of years with the practice, current and
past job responsibilities, percentage of time employed,
and any characteristic personality traits identified
during data gathering. Individuals or groups outside
of the practice that significantly influenced the system
were also included (eg, other clinics in Figure 3).
Once the basic genogram structure had been constructed,
it was expanded by asking the research nurse
about functional and emotional relationships observed
in the practices. Information was gathered in areas
indicated by the questions listed in Table 1, which
were developed from our own experience and from
recommendations outlined in Webber et al. 30 A footnote
process was used to highlight important information
about a group or individual. Once the pen and
paper version of the genogram was completed, computerized
practice genograms were prepared using
Visio ® 4.0, a software program specifically designed
for creating flowcharts, network diagrams, organization
charts, and cause-and-effect diagrams (Version
4.0, 1995, Visio Corporation, Seattle, 206-521-4500).
We have found that the length of time spent in the
field has an impact on the depth of understanding.
Figure 4
Vol. 30, No. 7
More Complex Practice Genogram Obtained After 2 Weeks of Practice Observation
FOOTNOTES:
1. “Bee in bonnet” about prevention—
wants to make changes
2. Left in 1992 after 7 years because of
conflict with practice—now works
for competing practice
3. Considering retirement in a few
years
4. Concerned about practice survival if
MD #1 retires and MD #2 leaves
5. Supports projects of MD #1
493
Figure 3 shows a typical genogram after 2 days in a
practice. Positive relationships were readily discernible,
but there were no conflicts identified. After more
extensive time at the practice (2 weeks), the picture
became more complex (Figure 4), and some conflicts
came to light. In our experience, it required a minimum
of 1–2 weeks in the practice, depending on the
number of physicians and staff, to get these types of
details. Anecdotally, we have given reports to six of
the 11 practices. In five of those six, we received positive
feedback about the perceived validity of our
analysis, including the genogram.
The Case Western Experience: Practice Genograms
as Interview Guide
Researchers at CWRU developed an alternative
approach to practice genograms for their clinical trial,
Study to Enhance Prevention by Understanding Practice
(STEP-UP). This trial sought to increase prevention
activities in randomly selected practices by tailoring
office-level interventions based on a 2-day
assessment of office practices. In the STEP-UP protocol,
an initial practice genogram was completed by
a research nurse during her first visit to each prac-

494 July-August 1998 Family Medicine
Table 1
Questions Used to Construct Genograms
• Who are the key members of the organization and what are their roles
(formal and informal)?
• What are the demographics for these individuals (age, gender, length
of employment, etc)?
• What are the important hierarchies, coalitions, triangles, and boundary
problems in the organization?
• How do the individuals and subsystems relate to each other with respect
to professional roles and personal relationships?
• What stage of the “life cycle” is the system in?
• What are the important recent events or historical events that have
shaped the practice?
• How has the organization responded to recent changes?
• What are the implicit and explicit belief systems within the practice?
• Who are the most overtly and covertly powerful people in the system?
• What is the overall communication style?
• How is power shared in the system?
Table 2
STEP-UP Interview Guide for Developing a Practice Genogram
Opening statement
“I’m _____ from STEP-UP project. The practice is participating in _____. My role in STEP-UP is
_____. I’m drawing an organizational chart to help me understand your practice.”
Initial questions Follow-up questions
“Who works here?” Demographics
“Who works with whom?”
“Who’s in charge?” “Who makes decisions:
about patient care?”
about personnel issues?”
about office operations?”
“Who reports to whom?” “Who supervises?”
“Who can tell people what to do?”
“How do the physicians communicate with each other? “Who are most powerful?”
“How do physicians and staff communicate?”
“How do staff members communicate?” “If you really want something done, who
do you go to?”
“What are recent events or changes?” “Who has left?”
“Who owns the practice?”
“Who is responsible for:
patient care?”
patient intake?”
patient discharge?”
billing and insurance?”
patient education?”
immunizations?”
“What outside organizations affect the practice?”
STEP-UP—Study to Enhance Prevention by Understanding Practice
tice. The purpose for this initial visit, as presented to
the practice, was to “get to know how the practice
functions and learn who’s who.” The process began
with the research nurse conducting brief structured
interviews (Table 2) with the practice manager or lead
physician and proceeded to interviews with other informants.
To enhance validity and reliability, an
emerging genogram was shared with other key informants
with both similar and different roles in the office.
These informants were asked to expand on, confirm,
or disconfirm what had already been written.
Also included in the assessment were medical record
reviews; a structured practice environment checklist;
brief qualitative field notes dictated by the facilitators;
questionnaires completed by physicians, staff,
and patients; and several patient-path diagrams. 1 Subsequent
triangulation of information from these multiple
sources was used to construct the final practice
genogram. This was then used as one of the feedback
tools when the facilitator subsequently met with the
practice staff to plan their prevention enhancement
intervention.
Genogram Construction: A
Case Example
The role of the practice
genogram is to provide a clear
and succinct portrayal of an
organization’s relational dynamics
that highlights important patterns,
strengths, and vulnerabilities.
It focuses on multiple people
and processes, using the organizational
chart as a starting point,
just as a family genogram uses a
family tree. Multiple sources of
data are combined to understand
the complexity of a practice system.
These can include checklists,
surveys and questionnaires,
observations, interviews, and
medical record reviews.
To illustrate the process, a fictitious
practice was created based
on several sites in the Nebraska
study. Figure 2 is the organizational
chart of the fictional practice,
indicating formal levels of
power, authority, and responsibility;
Figure 4 is the final genogram.
It reveals the greater complexity
of the practice by including information
on other important parts of
the larger community system (eg,
other clinics and physicians) and
some of the key relationships
among the physicians and staff.

Educational Research and Methods
As shown in Figure 4, the important relationships
identified in the fictional practice included the following:
1) There is a competitive/conflicted relationship
with the two other practices in town. 2) A previous
partner (MD #3) left the practice after having disagreements
with the senior physician (MD #1) and
now works for a competing practice. 3) While MD
#1 and MD #2 have an amicable relationship, the relationship
between MD #1 and the physician assistant
(PA) seems closer, as is that of MD #1 and the
office manager. 4) MD #2 has a distant relationship
with the PA and an amicable, but not close, relationship
with the office manager. 5) The office manager’s
relationship with the nurse (RN) who works with MD
#2 is conflicted.
MD #1 is considering retirement, which turns out
to be an important issue in this system. The office
manager has shifted away somewhat from the exclusionary
triangle represented by MD #1, the PA, and
the office manager. She voiced concern that the practice
would probably close if the new physician left as
the previous one did. At the same time, MD #2 wants
to do some new things (prevention) that threaten the
“old ways,” and he gets the RN involved in his new
projects. This alliance seems to create tension between
the office manager and the RN, possibly related to
some perceived change in the power relationship.
The strengths of this system include the positive
relationship between the two physicians, the current
positive relationship between MD #2 and the office
manager, the office manager’s vested interest in keeping
MD #2 in the practice, MD #2’s interest in prevention
and willingness to make changes, and the
close relationship between MD #2 and the RN and
her willingness to participate in change. The vulnerabilities
include the many levels of conflict that undermine
cooperation and change, the strong coalition
between MD #1, the PA, and the office manager that
has been exclusionary in the past, and the lack of
strong internal motivation for change on the part of
this coalition.
A reasonable but yet-to-be-validated hypothesis is
that any planned intervention to change aspects of
the system must account for these patterns of relationships.
In this case, a possible opportunity to facilitate
change in this practice might rest in the relationship
between the office manager and MD #2.
Given the office manager’s key role in the day-today
functioning of the practice and MD #2’s interest
in increasing preventive activities, it is plausible that
fostering a creative alliance between the two of them
that had mutual benefit might result in positive, and
possibly enduring, change.
Issues in Using Genograms
As is true when using any type of research or assessment
tool, certain assumptions and limitations
must be kept in mind. This is especially true for the
Vol. 30, No. 7
495
practice genogram because it deals with emotional
and relational issues, areas in which people and organizations
often feel most vulnerable. Issues of confidentiality,
how the information is gathered and used,
and ethical issues are important. The following are
some issues with which we have dealt.
First, genograms are tools used to generate hypotheses,
which must then be validated to be useful. Because
they describe dynamic relationships, genograms
are always considered to be in progress. Genograms
describe the way things may be now, but things can
change at any time. Genograms can be used to describe
outcome but usually only in the context of having
a picture of how things are now as compared with
a previous genogram of how things were then.
Second, genograms are intended to be positively
therapeutic and should never be used in a way that
could injure the people involved. In family therapy,
genograms are shared with the family when it is perceived
that doing so will be therapeutic and used in a
positive way.
Third, genograms and systems theory constructs
are complicated and easily misinterpreted or misused
by those unfamiliar with them. Most family practice
residencies teach these techniques and theoretical perspectives,
and, thus, most family physicians are familiar
with them.
These precepts also hold for practice genograms.
One approach to dealing with these ethical precepts
is to fully involve the participants in genogram construction
and to keep the genogram process available
for their ongoing use. In the Nebraska study, for example,
where more time is spent in each practice and
the goal is descriptive understanding rather than intervention,
we chose to share selected information on
a case-by-case basis. Each practice is given options
for different levels of feedback on our findings, including
hypotheses generated by the genogram.
Discussion
It is inevitable that primary care practices and other
aspects of the health care system will change. 31-35 It is
our experience that efforts to change practices should
be preceded by efforts to understand them. 9,36 While
primary care practices have much in common, our
research suggests that each is uniquely configured in
response to the particular needs of its clinicians, staff,
patients, and environment. Practice genograms have
been useful to us in understanding these issues.
To date, the lack of measurement methods that
could increase our understanding of practice dynamics
and characteristics have limited our success at
understanding change. The practice genogram is one
attempt to address this deficiency. Currently, it should
be considered a research tool, because we do not feel
that it has been sufficiently studied to recommend it
for application as a practice management tool.
Nonetheless, given their familiarity with the tool

496 July-August 1998 Family Medicine
and concepts, many family physicians could consider
experimenting with practice genograms during their
individual efforts at change, keeping the previously
mentioned caveats in mind.
Theoretically, using practice genograms to understand
practices prior to interventions is likely to have
important consequences. First, the genogram may
identify “lever points” in the practice through which
small efforts could result in large changes. 36,37 The
genogram may also identify approaches that are unlikely
to be effective in a particular practice and may
highlight unforeseen consequences of a planned intervention.
Just as important, practice genograms may
provide insights into the underlying reasons for current
configurations and operations of practices.
Whether the practice genogram is practical or costeffective
as a general change technique is yet to be
proven. The family genogram has proven helpful in
family medical problems. For understanding the
seemingly irrational and often paradoxical behavior
of medical practices, the practice genogram contains
exciting possibilities.
Acknowledgments: The authors express their thanks to Diane Dodendorf,
PhD, and Virginia Aita, PhD, for their invaluable assistance in the development
and application of the practice genogram technique, Connie Gibb,
RN, for her dedicated work in data collection, and Carol Gilbert, MS, for
her assistance with research design. Portions of this work were supported
by grants from the National Cancer Institute (1R01 60862 and 2R01
60862), the Agency for Health Care Policy and Research (1R01 HS08776),
and the Nebraska Cancer and Smoking Disease Research Program.
Corresponding Author: Address correspondence to Dr McIlvain, Department
of Family Medicine, University of Nebraska Medical Center, 600
South 42nd Street, Omaha, NE 68198-3075. 402-559-5367. Fax: 402-
559-8118. E-mail: hmcilva@unmc.edu.
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