Post-it Sunday 11/13/22-Cholelithiasis and the 4 Fs no longer apply?

The post-it reads “Lap Chole patients when I was a new nurse, 40, fat, female, flatulent… certainly has changed”.

Before I graduated from nursing school in 2001, what was taught to the nursing students about the four Fs was that the usual gall bladder patient was over 40, was female, was fat, and suffered from flatulence. I distinctly remember this being a topic for a lecture day. And me, being 25, was sure I would never get there.

Um, honey?

Time happens to us all.

And that is not at all the case anymore.

If, indeed, it ever was.

Now that I have been working the OR for 21 years and have done many, many, many gallbladder removals, I can say that this is not the case.

The youngest gall bladder surgery I’ve been involved in was an 18 year old female. And the oldest was a 92 year old man.

This brings to mind so many research questions. Where did the mnemonic come from? Does age have anything to do with it? Does gender have anything to do with it? Is the increasing incidence of other patients that do not fit the mnemonic have anything to do with the now standard laparoscopic approach?

I know that cholelithiasis is a real health problem, impacting many people of all ages, and genders. I’ve seen necrotic gallbladders, and gallbladders with gallstones the size AND color of a robin’s egg. I’ve seen perfectly normal appearing gallbladders that were removed because we were there and the surgeon had thought that it was causing the patient’s symptoms. I’ve seen malignant gallbladders, this is sad and a serious cancer. I’ve casually suggested to a pregnant coworker that the pain under her ribs on the right side might be caused by a sluggish gallbladder (I was right). I’ve prodded my husband to get his gallbladder checked out at age 36 when he would not stop complaining about right sided shoulder pain after eating fast food.

But what I think bothers me about the mnemonic is the casual misogyny of it.

It reeks of there there little lady smugness. And the paternal surgeon who will fix this female.


In a published study from 2013, the group recognized that the age of 40 was no longer relevant. And they posit that the F word for family history be substituted. Published in a journal I had never heard of, but published all the same.

In a what came first the chicken or the egg thought, maybe more women are diagnosed because they are the ones who have the most contact with medicine type people. We all know men who would rather reattach their own thumb with a stapler than see a doctor. I know I certainly do. I also know women like this but women have been told it is better to see doctors more frequently for girly things. And women who are of childbearing age and internal parts are more likely to engage with healthcare providers because of pap smears and other gynecological care that is needed, including pregnancy.


I will have to put that thought to bed until I have enough education to fully deal with it.

Take 2 tums and see be in three years when I am done with school.

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