No, acing the cognitive test does not make you fit to function as president

[This was written before all the events in Congress leading to the shutdown.]

Let's be clear about what just happened in President Trump's physical exam done last week by the White House physician, Dr. Ronny Jackson, who is a Rear Admiral in the Navy and was appointed as White House physician in 2006 during the George W. Bush administration.

Dr. Jackson declared Mr. Trump's physical health to be "excellent." He does have a disturbingly high "bad" LDL cholesterol level of 140 (normal is less than 100;  his total cholesterol is 223), even though he is already taking a statin to reduce it.   However, he passed an exercise tolerance test, so Dr. Jackson concluded that he has no clinical evidence of heart disease.   Technically true, based on lack of having already had a heart attack.  But this is a high risk factor;  and his clinical status could change overnight.

Equally troubling are Mr. Trump's borderline obesity -- just one pound under what would put a man of his height in that category -- and his fast-food, high-fat diet and lack of exercise other than hitting golf balls (he uses a golf cart to get from one hole to the next.)   These risk factors are somewhat offset, according to Dr. Jackson, by the fact that he has never used either alcohol or tobacco in any form, and his blood pressure is normal without medication.

Since Dr. Jackson gave his public report on Tuesday, several cardiologists have objected to his rosy characterization, some saying that his cholesterol level, his diet and his weight are high risk factors.   On the other hand, he lacks other risk factors of hypertension, smoking, and strong family history of heart disease.

What people have been more interested in, however, is the president's mental state.  Dr. Jackson said he saw no indication for doing any cognitive testing (because he sees the president almost every day (as he travels with him and has a sense of his mental status).   But the president asked to have it done, so he took the more extended version of the Montreal Cognitive Assessment, scoring a perfect 30 out of 30.  Needless to say, Team Trump is crowing about that.

But it's important to know what the test does and doesn't do.   It tests ability to name objects, to repeat immediately, as well as later, a series of numbers read to him.  It tests verbal facility by asking him to name as many words as he can that begin with a letter selected by the tester.  It also tests ability to pay attention by having to repeat backward a series of numbers given to him.  You also have to draw a copy of a geometric figure and other such simple tests.

It's a good screening test for someone you think has early signs of dementia.   It would indeed be very, very troubling if a president could not pass it.   But it is a minimal screening test of cognitive ability.  It in no way measures a person's ability to use the higher functions of judgment, integrative thinking, discretion, integrity, application of history to current situations, ability to work in a negotiating way with both allies and adversaries.   Nor can it test for character pathology or wisdom and for concepts of right/wrong at a higher level.

I'm not suggesting that Dr. Jackson implied that the test can do any of that, although he summed it up, rather jocularly, by saying that the president exceeded the passing score of 26 out of 30 right answers by getting all 30 correct.   "So, he is ready for duty," an old military phrase.

What concerns me is that the Trump team will imply that he has been certified on all that -- therefore trying to silence any legitimate concerns about the inadequacies so readily demonstrated in Trump's everyday actions that we are able to observe in real time.

Being able to repeat some words given to you 30 minutes ago has no bearing on understanding the centuries-long history of conflict between Suuni and Shia Muslims and applying that to understand the current intractable controversy rampant in the Middle East.  Being able to distinguish a drawing of a rhinoceros from a camel on a test doesn't give you a clue of how to resolve the conflict with North Korea.   

Let's don't oversell the product here.   We have a problematic president, not just in policy (which is bad enough) but in the specific ability to perform the tasks needed to accomplish very complex executive and leadership functioning.   As Dr. Richard Friedman of Cornell Medical College says:  "The fact is that Americans already have all the data they need to judge Trump's fitness."

Ralph