FILMS is a system for image interpretation. It’s a set of headings that break the task down into small steps, and by following the steps you will increase your accuracy and confidence.
F is for FIND. Look at the image and find anything that’s abnormal. You don’t try and analyse it yet, but FIND is about searching in an organised way so that you don’t miss things – or that you can be certain that there is no abnormality present. After this stage you will say something like, “There is an abnormality in the lower part of the chest on the left side.”
I is for IDENTIFY. What, at a simple level, makes you think there is an abnormality? Is part of the lung too light or too dark? Are there branching low-density areas within it? Is there bowel which is too big, or has abnormality of its wall? Is there a dark line across a bone where there shouldn’t be one? Part of IDENTIFY can be deciding where the abnormality is before what it is: in the chest for example, is it in the pleura or the lung? After this the statement might be, “There is an area of airspace opacity in the lower part of the left lung, containing a cavity.”
L is for LABEL. Is the white area on the chest X-ray due to airspace consolidation? Is the enlarged bowel part of the colon or the small bowel, or perhaps the stomach? Here you could get to, “There is a cavitated area in the lower part of the left lung which could be due to a lung abscess or a cancer.”
M is for MATCH. What do you know about the clinical history of the patient, and can you match the history to the abnormality on the X-ray? One appearance could have one of several causes, as above. Unless there is a finding with no alternative diagnosis to be considered, such as a fracture or a pneumothorax, you need a clinical history. So the statement after MATCH could be, “Cancer is more likely than pneumonia as the patient does not have a fever or a raised white cell count.”
S is for SUMMARISE. Bring it all together and write it down or tell somebody.
Do you have to do this for every case? No of course not. I’m not saying you should think, “there is a dark line between two parts of the bone” – your brain skips the first parts and says, “There is a fracture.”
But all that means is that the process has become automatic. I don’t consciously think my way through these steps every time I look at an X-ray, but I believe that my brain is still following the FILMS pathway.
But when you are starting out, or you want a way of organising yourself when confronted with a complicated image, you will find that consciously following FILMS is a useful support.
Of course, it doesn’t stand alone. To FIND all the abnormalities you need to be using a good search pattern. To IDENTIFY abnormalities you need to have a good idea of anatomy and the basics of pathology. To LABEL them you need to understand how and why different disease processes look the way they do on X-ray, and what the list of possible causes might be. And to MATCH them you need a broad knowledge of the illnesses that are common in your area and what the look like on X-ray.
This sounds like a lot to know, and it is.
But always remember – you will not and cannot possibly know all the answers!
Your job is only:
1) to say an image is normal; or
2) to make a diagnosis of a common local disease that can be treated locally such as pneumonia or TB; or
3) to detect an abnormality and say that you don’t know what it is.
To see examples of FILMS being used, go to any of the Cases, or visit the Topic on FILMS in chest X-ray interpretation.