Let me preface this essay by saying that I am an expert in
assessing cognition and cognitive disorders based on my 35 years as a psychiatrist doing that specific
job in acute care settings, outpatient clinics, nursing homes and other
healthcare centers, guardianship and conservatorship proceedings, and contested
hearings about decisional capacity. For 15 years I ran a Geriatric Psychiatry and Memory Disorders Clinic. I
have made positive diagnoses of the various forms of dementia, detected and
treated reversible forms of cognitive impairment, and corrected misdiagnoses of
dementia. So, I was more than slightly taken back by all the armchair
diagnosing of President Biden during the debate last Thursday. The press got
(at least) – 3 days of sensational and speculative headlines. I just saw a poll
today that showed an increase in the number of Americans who think “President
Biden has a cognitive problem” from 35% prior to the debate to 70% after the
debate. As an expert – with no special
knowledge of the President’s health status I can tell you why there is no
sufficient information to make that determination. I also have doubts about what “cognitive problem”
means to the average American based on the hundreds of family conferences I
have had to explain that concept.
Just based on the debate, the President’s responses and
overall presentation were suboptimal - but there are many untouched
explanations. I would describe the resulting press as excessive and
discriminatory against Biden. Here are a few possible explanations:
My first thought was he was over preprepared and probably
angry about having to confront a liar and a propagandist. Let’s face it – this is the first time any
Presidential debater has been forced to do this. Trump is the first convicted felon and repetitive liar
in any presidential debate. He is good
at it. Recall how Trump made his fellow
Republican primary candidates look in those debates. Many of them were speechless and
ineffective. Trump’s propaganda style
clearly makes it difficult for the media to criticize him. He effectively neutralized the moderators who
were unable to get him to answer questions.
Some in the press described him as a “ball of energy” rather than a
“ball of lies”. They know that no matter what they say – Trump is repetitive
and successful in wearing them down. The
best example is “The Big Lie” about how the election was stolen but there are
more. He maintains lies in the face of solid evidence and even the press does
not know how to handle it. They eventually acquiesce and start to treat the propaganda
as fact. During the debate he was able
to not provide responses to questions while repeating his own brand of
propaganda.
Second, the cognitive task was much more demanding for Biden. In the news leading up to the debate there
was clear messaging from both camps on how they were being prepared. Trumps
preparation was clearly casual and not information intensive. That was
reflected exactly in his ease with repeating his overlearned propaganda,
dodging solid answers to questions, and ad hominem attacks on Biden. The Biden camp reported an intensive schedule
of fact-based mock debates and attempting to answer moderators’ questions based
on much more factual content. Clearly
the Trump strategy presented a markedly lower cognitive load and practically no
information content to memorize.
Third, a single debate is not a marker of much – recall
Barack Obama’s problematic debate from 2012 when CNN stated that Mitt Romney
“trounced” Barack Obama in a debate. That is one reason Obama came out two days
ago with the statement that “bad debates happen”.
Fourth, choking in a presentation even substantially should
be a common experience. Public speaking is an almost universal fear. It
happened to me in a memorable incident where I found myself suddenly blank and
thinking about driving across Montana – as I was presenting in a pharmacology
seminar in medical school. I was about
26 years old at the time. My professor snapped me out of it by reminding me
where I was and what we were doing. I was intensely prepared and sleep deprived
at the time. Since then, I have found that the ability to focus and pay
attention to what is happening in a presentation is inversely related to
preparation intensity. In other words –
if I overprepare, I am likely to get bored with the content and will find my
mind wandering in the presentation even to the point that I do not want to be
there. Now, once I have the content mastered – I stop studying it and my plan
is to just free associate to the bullet points. President Biden had no bullet points.
Fifth, the reaction of the pundits has bordered on mass
hysteria. Their conclusions that Biden is acutely impaired and too “feeble” has
very little basis in fact. Several people including some pundits have described
talking to Biden and noticing that in his face-to-face conversations there is
no doubt that he is capable and mentally competent. The fact that he seemed like his old self
immediately after the debate in a Waffle House and the next day in a rally also
defies the common explanation of what happened in the debate – that he is
somehow irreparably impaired. I also had some interesting reactions to this
when I was contacted and asked about “what they gave Biden after the debate
that brought him back to normal.” To my
knowledge there is nothing. Memantine was
suggested to me, but as a physician who has prescribed this medication for cognitive
problems the results are far from impressive. The real question is whether he took anything for cold symptoms before the debate. Typical medications used have clear cognitive side effects.
Sixth, time of day – the debate started at 9 PM and went to
10:30 PM Eastern time. Circadian rhythms
are important. Drawing on my own
experience I would never schedule a presentation or a lecture in the
morning. I am not a morning person and
that is probably the main reason I did not elect to go into a surgical
specialty. I could not imagine trying to
concentrate intensely in the early morning hours. The later in the day the
better. I don’t know Biden’s typical schedule but speculate it is loaded in the
mornings rather than evenings.
Seventh, Biden’s longstanding articulation disorder. He has never tried to cover it up. It is a
life long problem with no cure, but he has discovered some management
strategies. It is probably worsened by stress and changes in voice quality from
a recent cold.
Eighth, the pervasive ageism bias has never been more
real. The next day Biden observed that
he doesn’t walk, talk, or debate like he did when he was a young man but he is
still competent to do the job. His record of accomplishments in the face of an
obstructionist party and their Supreme Court - backs him up.
If anything, the debate has taken the focus off Trump’s
severe deficiencies. There were several
attempts to fact check the candidates and it was clear Trump had 3 to 4 times
as many inaccurate statements. Some were
obvious like the stolen election and infanticide propaganda. Like all propagandists – repetition seems to
work on an unknowing or willfully ignorant public. Apparently, Mussolini was
such a skillful propagandist that some of what he said is still believed as
accurate today. In this case the focus
on Biden has basically given Trump and the MAGA GOP a free pass and they have
been emboldened to the point of suggesting the 25th Amendment be
invoked against Biden based on a 90-minute television broadcast.
Rather than provide another point-by-point contrast between
the candidates like I have done in the past there is a simple thought experiment
that involves common sense thinking that can be applied. It is not based on
wishful thinking or speculation. It
involves looking at the Presidency like a job application. Anyone who has ever
applied for a job knows that you need to get recommendations from previous
employers, supervisors, and in some cases co-workers. The Presidency is interesting from this
perspective because – all the coworkers are hand selected by the President
himself. Of the 15 cabinet level positions in the Trump
administration only 6 people endorse him for re-election. Eleven do not. That number does not add up to 15 because of
the turnover in the Trump administration and there are probably more people
that I missed. In addition, the most
recent same party President George W. Bush and 2 of his 3 Chiefs of Staff, and a
National Security Advisor do not endorse Trump in some cases criticizing him with
the harshest possible language. I am not
aware of a single Biden staffer who has not endorsed him and President Obama
came out with a statement of his support after the debate.
Although a direct comparison of Trump versus Biden is not
possible on Cabinet level endorsements because of the lack of a survey of the
Biden cabinet – the Trump results are striking based on the level of vehement criticism
and what they say about the former President’s intelligence, inquisitiveness,
and character. A direct comparison
across multiple dimensions is possible in the
survey that President Biden described during the debate. Presidential scholars rank Presidents across
a number of dimensions and in that process, Biden ranks number 14 and Trump is
dead last at number 45. Refer to the link for the specifics and outside
validation. The survey has received no coverage
post debate relative to President Biden’s performance – even though it is an
acknowledgement of his administrations’ accomplishments and a stark contrast to
Trump’s rhetoric about how Biden has “destroyed” the country (he used the word destroy
22 times) and he is the “worst” President – (he used the word worst 22 times). That contrast alone reveals Trump’s strategy.
That is my analysis of the debate from the perspective of a physician who has done thousands of cognitive and decisional capacity examinations. To be clear, I have no way of knowing whether my suggestions are accurate. I have not examined either candidate or their medical records. But I know that it takes a lot more to determine a person’s cognitive capacity than what we saw in that debate. The most straightforward solution would be to have each candidate take a standard assessment of their cognitive status and release the results to the public – but politics rarely takes a rational approach. In the meantime, it is best to avoid the assessments of partisan politicians and party members, comedians, and gossip show pundits.
This is not a laughing or pitiable matter.
George Dawson, MD, DFAPA
References:
1: Nicholas P,
Liebowitz M. Dozens served in Trump’s
Cabinet. Four say he should be re-elected.
NBC News July 30, 2023 https://www.nbcnews.com/politics/donald-trump/trump-cabinet-endorsements-rcna96648
2: Joint Statement from Elections Infrastructure Government Coordinating Council & the Election Infrastructure Sector Coordinating Executive Committees. November 12, 2020. Accessed July 1, 2024 https://www.cisa.gov/news-events/news/joint-statement-elections-infrastructure-government-coordinating-council-election
This was known within days of the 2020 election. It is still not accepted by former President Trump and MAGA Republicans:“The November 3rd election was the most secure in American history. Right now, across the country, election officials are reviewing and double checking the entire election process prior to finalizing the result.
“When states have close elections, many will recount ballots. All of the states with close results in the 2020 presidential race have paper records of each vote, allowing the ability to go back and count each ballot if necessary. This is an added benefit for security and resilience. This process allows for the identification and correction of any mistakes or errors. There is no evidence that any voting system deleted or lost votes, changed votes, or was in any way compromised."
Disclaimer:
As previously noted I am not now and have never been a
member of any political party in the United States. At the same time, it is clear to me that the
Republican party, their Presidential candidate Donald Trump, and their partisan
Supreme Court are an unprecedented danger to the United States that I have
known all of my life and that they should be defeated. It is also clear that
they have a level of organization that resulted in political advantages over
the opposition and that their rhetorical strategy is to blame the opposition for
what they in fact are doing.
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