The Importance of the Annual Physical

[ICTJOCK]

So was at my general doctor's office yesterday.   He's a great physician and we've always clicked.    I missed my physical in 2022,  so I got chided for that,  but mostly asked a lot of questions and got the update.   All very positive with the basics.

Due to family history,  I like to be tested with my blood sugar (for diabetes).    I go through everything,  including an HIV test  (which I do monthly,  but just not through my regular doctor).    I received a tetanus shot and recommendations on a variety of things upcoming.     

Was applauded with the continued  commitment to fitness and what a difference it makes.    The largest thing was the confidence the physical gives in knowing your health based on facts and testing.     It really adds positivity to your day and work!

[TJnDB]

Amen to that!  My brother in law would never go to the doctor or dentist until he was in pain.  Most of his teeth were removed due to rot.  Being in his late 60's, he made numerous trips to the bathroom every night. He finally went to the doctor went it became unbearable.  After some testing, his PSA was high and they discovered bladder cancer.  It was past point of treatment.  Within six weeks he was dead.  Maybe something could have been done if it was caught earlier.

I have a 6 mo checkup with my PCP on Thursday. Blood test has been completed and the results are good except my PSA.  It always runs high - 12 for this last check and it remains constant. However, I've had 2 biopsy's and 2 MRI's. All test show no cancer. So while my PSA is high getting routine blood work and DR visits helps me know I'm doing the right thing.  

[Guest]

Although frequently done (and Medicare will pay for it), there is no evidence that annual physicals improve health outcomes. For healthy people with no symptoms, the only portions of the exam shown to improve health are blood pressure measurements, BMI (weight for height), and pap smears. Dental visits are another matter, of course. It's foolish to ignore one's teeth to the point in which they need to be removed. Any new symptom should be evaluated, of course, especially any change in bowel or bladder habits of any sort. There is no screening recommended for bladder cancer, even in high-risk individuals (particularly smokers). Of course, any person who chooses to smoke cigarettes exposes himself to many dangers, most of which can barely be mitigated (though lung cancer screening for smokers/former smokers is advised starting age 50, but not as part of a routine physical). 

Evidence Brief: Role of the Annual Comprehensive Physical Examination in the Asymptomatic Adult

WWW.NCBI.NLM.NIH.GOV

 

CONCLUSIONS

• Comprehensive routine physical examinations are not recommended for the asymptomatic adult, although many patients and physicians continue to endorse the practice.
• Components of the physical examination recommended for the asymptomatic adult include:

  ◦

  blood pressure screening every 1-2 years

  ◦

  periodic measurement of body mass index

  ◦

  PAP smears beginning at age 21 for sexually active women with a cervix every 3 years up to the age of 65.

• There is some evidence that designating a specific visit for the provision of preventive services may increase the likelihood that patients will receive PAP smears, cholesterol screening and fecal occult blood testing.

Edited August 15, 2023 by Unicorn

[caramelsub]

I agree with Unicorn. I see my dentist twice a year for preventative cleaning, xrays, and examination. But my primary care only when I have symptoms. Doctors are always so busy, I would just feel like I’m wasting my time and the doctor’s time if I came to see him with no ailments. To each their own though. 

Edited August 15, 2023 by caramelsub

[+ purplekow]

While the physical itself may not reveal underlying disease, the yearly physical allows for the physician to insure that the patient is having routine testing done, vaccinations are completed, screening tests are done as needed.  A complete review of systems will also allow the physician to specifically ask about issues which the patient may consider minor but which may herald something more ominous.   If you only go to your internist when you are ill, it is likely that you will not be getting all the care that is recommended.   

Edited August 15, 2023 by purplekow

[Beancounter]

What used to be called an annual physical has now become an annual wellness check.  I’m not sure if this is because of Medicare or not.   My annual physical used to be a more thorough examination where my PCP would have me disrobe to my underwear, check for a hernia, check my prostate, look my body over for potential skin carcinomas, have a complete blood panel done, blood pressure check, urine sample given, etc.

I had my annual wellness check last week and was in and out in 10 minutes.  Aside from listening to my heart and checking my blood pressure that was about it.  I remained completely clothed for the duration.  We briefly discussed my blood results which were all normal.  Also, before the doctor came in the nurse asked me a few cognitive questions….what year is it? Count back from 20 by twos.  Name the months of the year in reverse order.

And, I had to request an A1C test because it wasn’t part of the regular blood workup.  
 

I suspect Medicare doesn’t reimburse doctors very much for this type of appointment and therefore the annual checkup is reflected in services delivered.  Of course, I’m required to go every year so I can have my prescription renewed for the next year.  

[Guest]

2 hours ago, Beancounter said:

...I suspect Medicare doesn’t reimburse doctors very much for this type of appointment and therefore the annual checkup is reflected in services delivered.  Of course, I’m required to go every year so I can have my prescription renewed for the next year.  

It's actually paid rather generously by Medicare standards: $166. That's why PCP's are eager for their patients to show up for them. None of the portions of the physical you mentioned are recommended by the nation's pre-eminent public health officials, the USPSTF. 

[BuffaloKyle]

I always go to the dentist twice a year. I love having my teeth cleaned! Being young I never got to the doctor really. I went for the first time in a long time right before the pandemic but hated the doctor I was assigned. He was pretty old and hard to talk to. So I dropped him after that. I just went the other month again to an office my Aunt goes to and I got assigned a doctor a year graduated from medical school. He's super cute and easy to discuss things with. Anything that pops up from now on I'll be able to take care of no problem.

[liubit]

2 hours ago, BuffaloKyle said:

I love having my teeth cleaned!

OMG, @BuffaloKyle, I hate it 😩😱

[ICTJOCK]

On 8/15/2023 at 4:11 PM, caramelsub said:

I agree with Unicorn. I see my dentist twice a year for preventative cleaning, xrays, and examination. But my primary care only when I have symptoms. Doctors are always so busy, I would just feel like I’m wasting my time and the doctor’s time if I came to see him with no ailments. To each their own though. 

Well I'll tell you what.   I value my health,  I'm a fitness advocate and I'm confident when I see preventative,  positive test on things like diabetes,  which affects my father's family.   There are so many good reasons for an annual check in,  including confidence in my own health maintenance,   I'd never consider not doing it.

[+ Charlie]

Our primary care doctor does a complete physical, including a series of blood and urine tests, hearing and strength tests, etc., every year. When my spouse happened to mention an unusual physical symptom he had recently experienced, the doctor suspected that he had had a mini-stroke, and immediately ordered other tests. Sure enough, it turned out that he had a partially blocked carotid artery, and within a few days a vascular surgeon operated on to clean it out. If it hadn't been for the routine physical,  it wouldn't have been caught, because my spouse didn't consider the symptom important enough for a separate visit to the doctor.

Of course, it's worth pointing out that we have had the same gay doctor for many years, and my spouse has a medical history that includes triple-bypass heart surgery.

Edited August 18, 2023 by Charlie
Additional info.

[NYCdadUES]

Can anyone recommend a doc in NYC? I saw mention of this guy for a high end concierge experience, but have not yet pulled the trigger as I hate going and it has been at least 10 years. 
 

anyone know or use him. Suggestions? 
 

[pubic_assistance]

On 8/15/2023 at 5:11 PM, caramelsub said:

I agree with Unicorn. I see my dentist twice a year for preventative cleaning, xrays, and examination. But my primary care only when I have symptoms. Doctors are always so busy, I would just feel like I’m wasting my time and the doctor’s time if I came to see him with no ailments. To each their own though. 

Well...I have to disagree. I have a history of heart failure with the men in my family so I've been doing an annual check up since my mid 40's. Because of that my doctor did track my cholesterol and noticed a slow but steady increase in-spite of the fact I keep a very healthy diet and exercise regularly. This allowed me to resolve the issue with a low dose 'statin before I had any problems. He's also identified a need for vitamin D supplements and occasional prostate swelling.  I wouldn't have been aware of any of this until I had a problem, and then the problem is a bigger issue to solve, than to not have the problem get past the early stages.

[Guest]

2 hours ago, Charlie said:

...When my spouse happened to mention an unusual physical symptom he had recently experienced.... If it hadn't been for the routine physical...

I think some posters on this string are confusing "routine physical" with the evaluation of a new unexplained symptom. It would be foolish to state that a new unexplained symptom shouldn't be evaluated by a healthcare professional. This is not the same as a "routine physical." And "routine physical" doesn't equate either with routine healthcare maintenance recommendations such as colon cancer screening, immunizations, or cholesterol screening. Of course, the benefits with some screenings are more robust than for others. The USPSTF does recommend cholesterol screening and statins in appropriate populations:

Recommendation: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication | United States Preventive Services Taskforce

WWW.USPREVENTIVESERVICESTASKFORCE.ORG

Recommendation Summary

Population	Recommendation	Grade
Adults aged 40 to 75 years who have 1 or more cardiovascular risk factors and an estimated 10-year cardiovascular disease (CVD) risk of 10% or greater	The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater.	B
Adults aged 40 to 75 years who have 1 or more cardiovascular risk factors and an estimated 10-year CVD risk of 7.5% to less than 10%	The USPSTF recommends that clinicians selectively offer a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 7.5% to less than 10%. The likelihood of benefit is smaller in this group than in persons with a 10-year risk of 10% or greater.	C
Adults 76 years or older	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating a statin for the primary prevention of CVD events and mortality in adults 76 years or older.	I

[Guest]

Sorry, but I have to continue my previous post on a different post. Although cholesterol screening is helpful, most people (even many physicians) overestimate the benefit. Among commonly recommended interventions, the NNT (number needed to treat for one person to benefit) for cholesterol meds is pretty high:

What are the odds that your medication will help you get better?

WWW.STATNEWS.COM

---

Although we think if a doctor prescribes a medication that it's going to help, a lot of therapies benefit very few patients.

"...Statins, which have become synonymous with “heart-attack-and-stroke-preventing,” have an NNT of 60 for heart attack and 268 for stroke: That’s how many healthy people have to take statins for five years for those respective outcomes to be prevented. In people with heart disease already, the number is smaller: Just 39 must take statins for five years for one non-fatal heart attack to be prevented, while 83 have to do so for one life to be saved. If 125 people with high blood pressure take drugs for five years to lower it, the meds will prevent a fatal stroke or heart attack in only one...".

And yes, if a person has a neurological event, doppler ultrasound imaging of the carotids is usually a good idea. For screening purposes, however, carotid doppler ultrasounds are actually harmful. The USPSTF gives that a D recommendation, meaning "Don't do it," or "It's Dangerous." A D recommendation means the data is known, and it's harmful, which is different from the I recommendation, which means the evidence is Insufficient or Inconclusive:

Recommendation: Asymptomatic Carotid Artery Stenosis: Screening | United States Preventive Services Taskforce

WWW.USPREVENTIVESERVICESTASKFORCE.ORG

Recommendation Summary

Population	Recommendation	Grade
Asymptomatic adults	The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. See the Practice Considerations section for a description of adults at increased risk.	D

[+ tassojunior]

I understand the importance of annual blood work and chemical tests and my MD gets those done for me. I also have a 50% one-side carotid artery that has to be checked every year. Every year Kaiser sends out a stool test to mail back and this year blood showed up evidently so I have to go for a colonoscopy. What I don't like is I had blood clots 2 years ago and while they followed up briefly on that, there is no regular follow up. Also I had a tiny growth that may have been cancer removed by the dermatologist 4 years ago but there is no regular follow up on that. I'm ok with lab tests as care and even follow ups to events but they don't do enough of them imho. 

[Guest]

8 hours ago, tassojunior said:

I understand the importance of annual blood work and chemical tests and my MD gets those done for me. I also have a 50% one-side carotid artery that has to be checked every year. Every year Kaiser sends out a stool test to mail back and this year blood showed up evidently so I have to go for a colonoscopy. What I don't like is I had blood clots 2 years ago and while they followed up briefly on that, there is no regular follow up. Also I had a tiny growth that may have been cancer removed by the dermatologist 4 years ago but there is no regular follow up on that. I'm ok with lab tests as care and even follow ups to events but they don't do enough of them imho. 

Where were the blood clots? If they were only small clots on a surface vein right under the skin, those often don't need follow-up. Those in deeper veins (or especially in arteries, of course) do need follow-up. Your "tiny growth" comment is also ambiguous. Are you telling us that you were never informed whether or not the growth was cancer? If you were told before the biopsy that the growth might be cancer, but the biopsy showed no cancer, again, follow-up might not be needed. You've provided insufficient information. If you were not informed whether or not the growth was cancer, one would simply hope that your doctor just didn't want to be bothered because it wasn't cancer, but that's not good practice. I'd find out for certain if I were in your shoes. 

[+ tassojunior]

9 hours ago, Unicorn said:

Where were the blood clots? If they were only small clots on a surface vein right under the skin, those often don't need follow-up. Those in deeper veins (or especially in arteries, of course) do need follow-up. Your "tiny growth" comment is also ambiguous. Are you telling us that you were never informed whether or not the growth was cancer? If you were told before the biopsy that the growth might be cancer, but the biopsy showed no cancer, again, follow-up might not be needed. You've provided insufficient information. If you were not informed whether or not the growth was cancer, one would simply hope that your doctor just didn't want to be bothered because it wasn't cancer, but that's not good practice. I'd find out for certain if I were in your shoes. 

The growth 4 years ago was not cancer and another tiny one 12 years ago was not cancer from my understanding but were removed in caution and tested. But zero follow-up after that from the dermatologist at Kaiser. I should make an appointment to get a couple small skin tags removed and let him look me over as he did 2 years ago. Appointments with dermatology take 6 months.

The clots concern me more as my neighbors both just died from clots after Covid. I had two, one in each lung, and the routine at Kaiser is the take-home shots for 10 days and then Pradaxa for 3 months the first time. A 2nd CAT scan showed complete clearing.......but still. With shortness of breath it's hard to tell if it's the air or your lungs. I'd rather have some sort of periodic follow-up scan or D-Dimer test of some sort. Of course after covid the pulmonary doc at Kaiser is swamped and I would have to go to Kaiser Urgent Care and complain of breath shortness to get a test. But I don't like to hack the procedure like that. (I also now wish they would do more GI CAT scans and fewer colonoscopies.) Being on Medicare with Kaiser Advantage makes me wonder if it's a cost-control thing for Medicare patients. There seems to two classes of patients. I'll pay extra if that's what it takes but that's not even an option with these Advantage programs.  

Edited August 19, 2023 by tassojunior

[Guest]

2 hours ago, tassojunior said:

The growth 4 years ago was not cancer and another tiny one 12 years ago was not cancer from my understanding but were removed in caution and tested. But zero follow-up after that from the dermatologist at Kaiser. I should make an appointment to get a couple small skin tags removed and let him look me over as he did 2 years ago. Appointments with dermatology take 6 months.

The clots concern me more...

If the growths were not cancerous, no dermatology follow-up is indicated. Skin tags are a purely cosmetic concern with ZERO malignant potential. No insurance in the world will cover removal of those, although if you were in for a different reason, your dermatologist or PCP may have removed them as a personal favor. When I worked for an HMO, any referral to dermatology for skin tags was automatically removed from the waiting list. Almost everybody gets skin tags, and dermatologists could spend all day removing them. Personally, when I get them, I just get some band-aids ready, and yank them off while I'm in the shower. I put on the band-aids when I step out of the shower. 

The follow-up on blood clots varies according to certain factors, the most important of which is whether the clot was provoked (there is a known cause, which will not be present in the future) or unprovoked. In the case of a provoked clot--for example, you were laid up in the hospital with one of the earlier strains of SARS-CoV2--then guidelines suggest 3-6 months of anticoagulation, then stop. Guidelines do not recommend follow-up with D-dimers, ultrasounds, etc. Personally, I tend to prefer closer to 6 months in low-risk patients, and closer to 3 months for patients who fall down a lot or who have other reasons for me to be extra concerned (such as history of intestinal bleeding). If you are concerned, I would suggest reading professional guidelines rather than relying on your personal intuition:

American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism | Blood Advances | American Society of Hematology

ASHPUBLICATIONS.ORG

---

Background:. Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000...

[+ tassojunior]

2 hours ago, Unicorn said:

If the growths were not cancerous, no dermatology follow-up is indicated. Skin tags are a purely cosmetic concern with ZERO malignant potential. No insurance in the world will cover removal of those, although if you were in for a different reason, your dermatologist or PCP may have removed them as a personal favor. When I worked for an HMO, any referral to dermatology for skin tags was automatically removed from the waiting list. Almost everybody gets skin tags, and dermatologists could spend all day removing them. Personally, when I get them, I just get some band-aids ready, and yank them off while I'm in the shower. I put on the band-aids when I step out of the shower. 

The follow-up on blood clots varies according to certain factors, the most important of which is whether the clot was provoked (there is a known cause, which will not be present in the future) or unprovoked. In the case of a provoked clot--for example, you were laid up in the hospital with one of the earlier strains of SARS-CoV2--then guidelines suggest 3-6 months of anticoagulation, then stop. Guidelines do not recommend follow-up with D-dimers, ultrasounds, etc. Personally, I tend to prefer closer to 6 months in low-risk patients, and closer to 3 months for patients who fall down a lot or who have other reasons for me to be extra concerned (such as history of intestinal bleeding). If you are concerned, I would suggest reading professional guidelines rather than relying on your personal intuition:

American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism | Blood Advances | American Society of Hematology

ASHPUBLICATIONS.ORG

---

Background:. Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000...

I'm clearly not qualified to tell if some tag or bump may be cancerous or not so I have the dermatologist look at them and they burn off what is harmless. At the same time the dermatologist does an inspection of my torso, arms and head for anything that looks suspicious to a trained eye. That annual routine works well for me as a skin check-up. But my Kaiser has gone from 3 dermatologists to 1 making appointments very hard. 

[Guest]

20 hours ago, tassojunior said:

I'm clearly not qualified to tell if some tag or bump may be cancerous or not so I have the dermatologist look at them and they burn off what is harmless. At the same time the dermatologist does an inspection of my torso, arms and head for anything that looks suspicious to a trained eye. That annual routine works well for me as a skin check-up. But my Kaiser has gone from 3 dermatologists to 1 making appointments very hard. 

Well, it looks as though you seem to have found a backhanded way to get Kaiser to pay for purely cosmetic procedures, and your dermatologist seems complicit. Obviously, you know that these are skin tags, as you called them that yourself. However, let's accept for the moment your false narrative that you have no idea what these are, and that you're truly concerned they might be cancerous or pre-cancerous. In that case, it would obviously make more sense to see your PCP promptly, rather than wait 6 months to see a dermatologist. The PCP could immediately reassure you regarding the benign nature of these lesions (he could just as easily get rid of them himself if he wanted, presumably without telling Kaiser about it). Is there any wonder, with behavior like this, why it takes 6 months to see a dermatologist at your Kaiser? One can only hope this hanky-panky doesn't cause delays in diagnosis for those with truly concerning lesions, nor delays in treatment for those with serious dermatological conditions like psoriasis, who truly need to see a dermatologist. 

[Rudynate]

On 8/18/2023 at 2:57 PM, tassojunior said:

I understand the importance of annual blood work and chemical tests and my MD gets those done for me. I also have a 50% one-side carotid artery that has to be checked every year. Every year Kaiser sends out a stool test to mail back and this year blood showed up evidently so I have to go for a colonoscopy. What I don't like is I had blood clots 2 years ago and while they followed up briefly on that, there is no regular follow up. Also I had a tiny growth that may have been cancer removed by the dermatologist 4 years ago but there is no regular follow up on that. I'm ok with lab tests as care and even follow ups to events but they don't do enough of them imho. 

How would they follow up blood clots? Either you have them or you don't.  Usually, after your first clotting episode, they do tests for clotting problems, but what else would they do?  I have a diagosed clotting problem. I've had a pulmonary embolus and more DVT's than I care to think about.  I'm on lifelong anticoagulation.  I know my hematologist very well.  If I even have a colonoscopy, they take special precautions.  To me, that's the followup for blood clots.  You don't want it if you don't need it. 

[+ tassojunior]

1 hour ago, Rudynate said:

How would they follow up blood clots? Either you have them or you don't.  Usually, after your first clotting episode, they do tests for clotting problems, but what else would they do?  I have a diagosed clotting problem. I've had a pulmonary embolus and more DVT's than I care to think about.  I'm on lifelong anticoagulation.  I know my hematologist very well.  If I even have a colonoscopy, they take special precautions.  To me, that's the followup for blood clots.  You don't want it if you don't need it. 

The time I had 2 large pulmonary clots we all just thought I was tired. My doctor only ordered a D-dimer test as an after thought when I was headed out the door. Since I've been off the anticoagulants I've felt that way often and it's a little scary to think it could be clots and I should be on anticoagulants. Most others I know are kept on them. And since covid it seems there's a lot more clots. I would think periodic D-dimer tests or at least more with symptoms.  

[Rudynate]

It seems your treatment was careless.  And that's the weird thing about blood clots - a lot of primary care docs just sort of blow you off and treat you like some sort of malingerer and they don't seem to appreciate that they are dealing with a potentially life threatenting condition.  They tell you - if you even suspect it's a blood clot, get to the hospital pronto, better to be safe than sorry, etc. etc.  But then, if you do, they treat you like a hypochondriac.  One time, I went in to see my PCP in San Francisco because of some soreness and swelling in one of my legs.  My PCP was almost contemtptuous as he declined to order an ultrasound. That was back before Kaiser's records were all digitized.  He had to order my imaging from a  facility in the East Bay and it took a couple days to get it.  When he saw the reports he called me back and asked me to come in right away for an ultasound.   Fortunately, that time was a false alarm.  

Another time, I was having clear-cut symptoms so I want into the Santa Rosa Kaiser - this was deep in the pandemic.  They did an ultrasound which came out negative and sent me on my way, in spite of my symptoms.  I wasn't satisfied - and my symptoms only got worse, so I went in to the San Franciso Kaiser when I got home and asked for a repeat scan - and I told them I didn't think the technologist in Santa Rose had imaged the correct veins.  They got very surly, the radiologist said that the scan from Santa Rosa was "perfect!!" But another radiologist who wanted to placate me had the technologist image some superficial veins - sure enough, there was a sizeable clot right at the junction of a superficial vein and a deep vein.   

Your treatment clearly sounds careless - I'm sorry that happened.  Was the d-dimer elevated?  There are other things that can cause an elevated d-dimer.  But an elevated d-dimer in the presence of symptoms is a whole other thing.

[Guest]

5 hours ago, tassojunior said:

The time I had 2 large pulmonary clots we all just thought I was tired. My doctor only ordered a D-dimer test as an after thought when I was headed out the door. Since I've been off the anticoagulants I've felt that way often and it's a little scary to think it could be clots and I should be on anticoagulants. Most others I know are kept on them. And since covid it seems there's a lot more clots. I would think periodic D-dimer tests or at least more with symptoms.  

Hopefully, our physicians are basing their decisions which are evidence-based, as determined by actual scientific study, and as summarized by professional guidelines. You have not provided enough details regarding your health to be provided with educated opinions, but there is a link to the professional guidelines several posts up, which you are free to peruse. One would hope that one's physicians are basing their decisions based on these professional guidelines, and not on "I'd think." You still haven't volunteered whether or not your clots were provoked or not, which is certainly your prerogative. As indicated in the guidelines, if your clot was unprovoked, serious consideration should be given to lifelong anticoagulation. Otherwise 3-6 months of anticoagulation is the recommendation of the consensus of the world's experts on the subject, and periodic testing in the absence of symptoms is NOT recommended. Anticoagulation definitely carries risks in addition to potential benefits. Obviously there are not so great doctors out there who might not be up to speed with professional guidelines. However, criticism of one's care should come from the basis of one's own study of guidelines, not on "I'd think."