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Validating the 5Fs mnemonic for

cholelithiasis: time to include family history
Gary Bass, S Nadia S Gilani and Thomas N Walsh

Postgrad Med J 2013 89: 638-641 originally published online August 9,

2013
doi: 10.1136/postgradmedj-2012-131341

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Original article
Royal College of Surgeons in
Ireland Academic Department
of Surgery, Connolly Hospital,
Dublin, Ireland
Correspondence to
Gary Bass, Royal College of
Surgeons in Ireland Academic
Department of Surgery,
Connolly Hospital,
Blanchardstown, Dublin 15,
Ireland; garbass@rcsi.ie
Received 30 July 2012
Revised 22 June 2013
Accepted 7 July 2013
Published Online First
9 August 2013
To cite: Bass G, Gilani SNS,
Walsh TN. Postgrad Med J
2013;89:638–641.
638
Downloaded from pmj.bmj.com on November 3, 2013 - Published by group.bmj.com
Validating the 5Fs mnemonic for cholelithiasis: time
to include family history
Gary Bass, S Nadia S Gilani, Thomas N Walsh
ABSTRACT
Background The time-honoured mnemonic of ‘5Fs’ is
a reminder to students that patients with upper
abdominal pain and who conform to a profile of ‘fair,
fat, female, fertile and forty’ are likely to have
cholelithiasis. We feel, however, that a most important
‘F’—that for ‘family history’—is overlooked and should
be introduced to enhance the value of a useful aide
memoire.
Methods To assess the usefulness of each of the
existing factors of a popular mnemonic, 398 patients
admitted with upper abdominal pain between March
2009 and April 2010 were studied. The clinical features
expressed in the cholelithiasis mnemonic in patients with
sonographic evidence of cholelithiasis were compared
with those of patients without.
Findings In the cholelithiasis group, significantly more
patients were women (150/198 (75.8%) vs 111/200
(55.5%), p<0.001), fair (144/198 (62.9%) vs 54/200
(32.1%), ( p<0.001)), fertile (135/198 (68.2%) vs 50/
200 (25%) ( p<0.001)) and had a body mass index >30
(56/198 (28.3%) vs 19/200 (9.5%) ( p<0.001))
compared with controls; but age over 40 years did not
predict cholelithiasis (82/198 (41.4%) vs 79/200
(39.5%) ( p=0.697)). In the cholelithiasis group, 78/198
(39.4%) had a family history in at least one first-degree
relative, compared with 27/200 (13.5%) of controls,
( p<0.001). Where the phenotypic elements of the
history existed in combination, that patient was found to
be at an increased risk of cholelithiasis.
Interpretation Our study found that the validated
‘students’ 5Fs’ mnemonic retains a role in clinical
diagnosis of patients suspected of cholelithiasis but the
factor ‘familial’ should be substituted for ‘forty’ in
recognition of the role of inheritance and the changing
demographics of gallstone incidence.
INTRODUCTION
Medical knowledge is hard learned. For genera-
tions, students of medicine and expert medical
practitioners alike have relied on certain strategies
for effective memorisation, accretion and recall of
important information.1 Who would hope to retain
the information contained in the Glasgow Coma
Score, or the Advanced Trauma Life Support
‘ABCDEF’ approach to assessment without these
being organised in useful aides memoire? In their
interesting study of memory formation, Dyson
et al2 point out that aides memoire also assist
fitting new data to old information (restructuring)
and promote fine tuning, allowing data to be
adapted to novel situations.
Mnemonics, the elements of one such strategy,
are defined as devices that promote efficient mem-
orisation and easy access to memory stores because
Bass G, et al. Postgrad Med J 2013;89:638–641. doi:10.1136/postgradmedj-2012-131341
of their novelty and familiarity3 or ‘memory
tricks’.4 Mnemonics are rightly considered to
improve data acquisition and recall,5 to facilitate
understanding,6 to improve motivation and enjoy-
ment,7 while supplying integration, meaning and
cues where none existed.3 The effectiveness of the
Advanced Cardiac Life Support mnemonics ‘4Hs’
and 4Ts’ and ‘EMD aide’ have been compared in a
randomised trial, which showed an advantage for
the latter.2 Indeed, the best aides memoires are so
catchy that they can ‘go viral’ without the user fully
understanding the meaning or the message.
Medical students have been taught, for at least
60 years,8 that the patients presenting with upper
abdominal pain most likely due to symptomatic
cholelithiasis can be identified by the mnemonic—
fair, fat, female, fertile and forty.9 One commenta-
tor wrote in the British Medical Journal in 1956
that “this description implies that obese multipar-
ous women who are approaching the climacteric
are especially prone to gallstone formation; if valid,
therefore, it may lead to a more precise definition
of the aetiology of gallstones—for example in
terms of endocrine disturbances affecting this
group of the population”.8 It has been our anec-
dotal experience, however, that there is a missing
‘F’—family history. This was recently illustrated to
the authors by the protestations of a frustrated
father who could not get the staff of a number of
emergency departments to investigate his
16-year-old daughter with right upper quadrant
pain for cholelithiasis, as they insisted she was too
young. He had pointed out that her mother and all
of her five aunts suffered from cholelithiasis. He
was ultimately proven to be correct.
The aim of this study was to assess the usefulness
of the current five ‘Fs’ mnemonic of clinical fea-
tures—and assess a sixth for ‘family history’—by
comparing the clinical features of patients admitted
for investigation of upper abdominal pain who had
sonographic evidence of cholelithiasis, with those
that did not. Quantifying the effect of each of these
clinical features, alone and in combination, allowed
us to create a novel, simple, reproducible scoring
system that illustrates cumulative risk in a patient
exhibiting multiple such features.
METHODS
Between March 2009 and April 2010, 398 con-
secutive patients admitted to Connolly hospital via
the emergency department for assessment of epi-
gastric and or right upper quadrant (RUQ) pain
were entered into this study. A complete history
was taken and physical examination and appropri-
ate laboratory tests were also performed. All the
patients had radiological investigations that
 Original article

identified whether or not they had cholelithiasis as part of their BMI

routine investigations. Those who were found not to have chole-
lithiasis went onto to have further investigations.
The patients were divided into two groups: Group1 those
with and Group 2 those without radiological evidence of chole-
lithiasis. The presence of the following clinical features was
assessed for each patient: fairness, obesity, gender, fertility (for
women—whether premenopausal or postmenopausal), age and
family history. Institutional ethics committee approval was
obtained for this study.
Definitions of each of the factors of the mnemonic
Patients were analysed with respect to each of the classically
taught 5 Fs based on the following definitions; ‘female’
(gender), ‘fat’ (body mass indeed (BMI) greater than 30), ‘forty’
(age greater or equal to 40), ‘fertile’ (one or more children) and
‘fair’ (Fitzpatrick Skin Class I–III (light) vs IV–VI (dark) and fair
versus dark natural hair colour) as well as the hypothesised sixth
‘F’, ‘family history’.
Data analysis
This prospective study was designed and reported in accordance
with the Strengthening the Reporting of Observational Studies
in Epidemiology guidelines. An initial pilot study of 100
patients was analysed to establish a baseline incidence of family
history of cholelithiasis in the control group. The study then
continued to accrue until it was powered to detect a 20% differ-
ence between groups at a β of 0.8.10 Statistical analyses were
performed with PASW V.18.0 for Windows. Categorical vari-
ables were compared using analysis of variance, and p values of
less than 0.05 were considered statistically significant. All of the
factors were then included in a hierarchical multiple linear
regression model to establish which were independent predic-
tors of cholelithiasis and to what extent each factor contributed
to a patient’s risk. The relative weight of these significant vari-
ables (derived from the OR) was then used to create a 12-point
predictive scoring system to quantify the cumulative risk of
more than one factor. Finally, a receiver-operator characteristic
(ROC) curve was created to assess the sensitivity and specificity
of our hypothetical scoring system in predicting a diagnosis of
cholelithiasis.
The cholelithiasis group had a mean (±SEM) BMI of 45.3
±1.01, while the control group had mean BMI of 46.1±1.02;
this mean difference in BMI between groups was not significant
(p=0.211). When patients in each group were categorised into
obese (BMI >30) versus non-obese (BMI </=30), the cholelith-
iasis group had 56/198 (28.3%) obese patients, compared with
19/200 (9.5%) in the control group (χ2=19.075, p=0.005).
Age
The cholelithiasis group had a mean (±SEM) age of 45.3±1.01
years, while the control group had mean age of 46.1±1.02 years
(p=0.581). Within groups, 82/198 (41.4%) patients with cholelith-
iasis and 79/200 (39.5%) control patients were over the age of 40
(p=0.697).
Fertility
Evaluation of the number of children as a continuous distribu-
tion (from 0 to 8 children in the study’s participants) revealed a
non-significant trend towards multiparity in the cholelithiasis
group. When patients were grouped into ‘no children’ versus
‘one or more children’, however, it was noted that 135/198
(68.2%) patients with cholelithiasis had children, compared
with only 50/200 (25%) in the control group ( p<0.001).
Skin colour
Patients in the cholelithiasis group were significantly more likely
to have fair skin (Fitzpatrick Skin Class I–III) than darker skin
(Fitzpatrick Skin Scale IV–VI); 144/198 (73%) of patients with
cholelithiasis had fair skin versus 85/200(42.5%) patients in the
control group (χ2=37.21, p<0.001). This directly correlated
with a 6-point natural hair colour scale, wherein the cholelithia-
sis group, 138/198 (69.7%) patients had a fair natural hair
colour versus 63/200 (31.5%) controls (χ2=58.073;
p=0.0005).
Family history
Seventy-eight of 198 (39.4%) patients in the cholelithiasis group
reported a positive family history of cholelithiasis in one or
more first-degree relatives (mother, father, sibling, child com-
pared with 27/200 (13.5%) patients in the control group
(χ2=39.174; p<0.0005).

RESULTS
The risk factors combined
Patient demographics
The elements of the mnemonic, which were found to be inde-
In total, 398 patients presented with epigastric/right upper
pendent predictors of cholelithiasis (female, fat, fair, fertile,
quadrant abdominal pain: Group 1 (n=198), whose ultrasound
findings confirmed cholelithiasis or acute cholecystitis and
Group 2 (n=200) controls, in whom abdominal ultrasound
did not demonstrate gallbladder pathology, underwent endos- Table 1 Points allocation for items of patient history predictive of
copy, which demonstrated gastritis in 90/200 (45%), oesopha- symptomatic cholelithiasis
gitis in 65/200 (32.5%) and duodenal ulcer in 45/200 (22.5%). Clinical Points scored for positive OR (from regression
feature history analysis)

Testing the students’ mnemonic Fair 3 points 8.085

Gender Female 2 points 7.347
The majority of patients in both groups were women, compris- Fat 3 points 8.996
ing 261/398(65%) patients, with 111/200 (55.5%) women in Fertile 1 point 2.559
the control group, but the gender disparity was significantly Family history 3 points 8.904
larger in the cholelithiasis group, with 150/198 (75.8%) women Total 12
(χ2=18.8, p<0.001). (This pattern was concordant with Irish All included clinical features were univariate and multivariate independent predictors
National Hospital In-Patient Enquiry (HIPE) data, which of cholelithiasis on regression analysis. Weighting was derived from the OR. The
reported that women patients accounted for 70% of hospital cumulative risk of cholelithiasis was increased significantly with points increase
(p<0.001) (figure 2).
admissions for cholelithiasis in 2009).

Bass G, et al. Postgrad Med J 2013;89:638–641. doi:10.1136/postgradmedj-2012-131341 639

 Original article

Figure 3 Receiver-operating characteristic curve graphing sensitivity

Figure 1 Number of clinical cholelithiasis score points. Comparison of
number of patients with cholelithiasis in low (five or fewer points)
versus high (six or more points) cholelithiasis score groups. Access the
article online to view this figure in colour.
family history), were entered into a multiple linear regression
analysis to assess the relative contribution of each to the
patient’s overall risk of cholelithiasis. The risk was found to be
cumulative in patients with multiple positive factors; based on
the calculated individual contributions of each of the five factors
to the overall risk, a 12-point ‘Cholelithiasis Score’ was created
(table 1). Patients who scored 6 or more points from a total of
12 were highly significantly more likely to have a diagnosis of
cholelithiasis on ultrasound than those patients with 5 or fewer
versus the reciprocal of specificity of a patient scoring 6/12 or more
points (ie, having multiple ‘Fs’ in their history) in predicting
symptomatic cholelithiasis on subsequent ultrasound. The diagonal line
represents the intercept (or ‘no discrimination’ line). Sensitivity and
specificity increases as the curve arcs more towards the upper left
corner. Access the article online to view this figure in colour.
points ( p<0.001; figures 1 and 2). When a ROC curve was
plotted, scoring 6 or more points was 67.2% sensitive and
89.7% specific in predicting the diagnosis of cholelithiasis in
our patients (figure 3). One hundred and fifty-nine of the 398
patients (39.9%) scored six or more points, with the remainder
(239/398, 60.1%) scoring five or fewer points.

Figure 2 Ultrasound-demonstrated
gallstones. A 4-quadrant population
pyramid demonstrating the proportion
of patients in the cholelithiasis and
control groups at each level of
cholelithiasis points score (0–12).
Patients in the upper right quadrant
are at highest risk, while those in the
lower left are at the lowest risk of
symptomatic cholelithiasis. A
statistically significant correlation was
seen between a high points score (in
excess of 6/12) and membership of the
cholelithiasis group ( p=0.001). Access
the article online to view this figure in
colour.

640 Bass G, et al. Postgrad Med J 2013;89:638–641. doi:10.1136/postgradmedj-2012-131341


DISCUSSION
Diagnostic algorithms taught in medical school stick with us
throughout practice; these valuable tools have been shown to
help in narrowing differential diagnosis. The predisposing factors
to cholelithiasis are recognised by medical students and public
alike as ‘fair’, ‘fat’, ‘female’, fertile’ and ‘forty’. There is a well-
recognised genetic component to the development of cholelithia-
sis disease, rooted chiefly in familial variations in lipid metabol-
ism, which has been confirmed in numerous studies.11–13
It seems intuitive, therefore, to consider the role of ‘family
history’ as a possible omission from the algorithm. This study
confirms that family history is indeed a valuable adjunct to the
quintet already established, and indeed, could or should replace
age as a significant predisposing factor.
Our study of 398 patients with RUQ abdominal pain is the
first quantitative and qualitative clinical validation of this mne-
monic. The value of each of the six predictive factors was
tested. The additional factor ‘family history’ was found to be
one of the strongest predictors of symptomatic cholelithiasis,
while ‘forty’ was the weakest, perhaps a reflection of an earlier
age-at-presentation that may be driven by an increasing preva-
lence of obesity in young adults.10–13
Our cholelithiasis score illustrates that good history-taking
can predict the presence of cholelithiasis, a common cause of
right upper quadrant abdominal pain, with 67% sensitivity and
90% specificity. This scoring algorithm, itself an aide memoire,
is not intended to supplant the use of ultrasound (which has a
sensitivity and specificity of over 95%) as the gold standard in
the diagnosis of cholelithiasis, nor would the authors advocate
performing an operation without confirmatory radiologic evi-
dence of cholelithiasis. It simply serves to demonstrate the preci-
sion and accuracy of a simple mnemonic in narrowing the
differential diagnosis and supports its retention as part of a
complete patient history.
In conclusion, the 5F mnemonic retains its relevance in
modern medical education but ‘familial’ should replace ‘forty’
to recognise the genetic component of cholelithiasis and the
changing age profile of patients presenting with gallstones in the
current age. The incorporation of these factors into a simple
score enhances the role of the mnemonic and focuses the
student on the likelihood of cholelithiasis.
Main messages
▸ Our validation of the 5Fs mnemonic illustrates that good
history-taking alone can predict the presence of
cholelithiasis.
▸ Even in the era of advanced imaging, the 5F mnemonic
retains its relevance in modern medical education but
“familial” should replace “forty” to recognise the genetic
component of cholelithiasis and the changing age profile of
patients presenting with gallstones in the current age.
▸ The incorporation of these factors into a simple score
enhances the role of the mnemonic and focuses the student
on the likelihood of cholelithiasis.
Bass G, et al. Postgrad Med J 2013;89:638–641. doi:10.1136/postgradmedj-2012-131341
Original article
Current research questions
▸ Are aide-mémoire in medical education truly valuable in
focussing students’ learning?
▸ What is the evidence-base behind them?
▸ Should they change (like the 5Fs) to better suit a changing
patient population?
Key references
▸ Patkin M. Surgical heuristics. ANZ J Surg 2008;78:1065–9.
▸ Dyson E, Voisey S, Hughes S, et al. Educational psychology
in medical learning: a randomised controlled trial of two
aide memoires for the recall of causes of electromechanical
dissociation. Emerg Med J 2004;21:457–60.
▸ Beitz JM. Unleashing the power of memory. The mighty
mnemonic. Nurse Educ 1997;22:25–9
▸ Scruggs TM, Mastropieri MA. Remembering the forgotten art
of memory. In: Cauley KLF, McMillan J, eds. Educational
psychology. Guildford, CT: Dushkin, 1995:92–8
▸ Horn G. Observations on the aetiology of cholelithiasis. Br
Med J 1956;2:732–7.
Collaborators Frank Leader.
Contributors GB: drafting of manuscript, analysis and interpretation of data,
critical revision of the manuscript for important intellectual content. SNSG:
acquisition of data, study supervision, drafting of manuscript. TNW: study concept
and design, critical revision of the manuscript for important intellectual content,
study supervision.
Competing interests None.
Ethics approval Connolly Hospital Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
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