A doctor to the presidents

Dr Jeffrey Kuhlman’s insights into providing care for US presidents are worth reading

So Donald Trump  is once again set to become President of the United States. He will take up the role at the age of 78.

Kamala Harris’s late entry to the race was precipitated by concerns about the health and fitness of 81-year-old incumbent Joe Biden. Who better to weigh in on the relevance of ageing and the presidency than the author of Transforming Presidential Healthcare: Ensuring Comprehensive Care for the Commander in Chief Amid 21st Century Threats, Dr Jeffrey Kuhlman.

Kuhlman has worked for three presidents: He served Bill Clinton as Marine One flight surgeon, overseeing the President’s health on board his official helicopter; George W Bush as Director of the White House Medical Unit; and Barack Obama as the President’s personal physician. And while he conscientiously preserves the privacy of his three presidential patients, the book provides some interesting insights.

Writing about his time with Obama, who appointed him as his personal physician in 2009, Kuhlman says each day he held the role was historic. He relates how Obama struggled with a long-standing cigarette habit and how Kuhlman tried to help him quit. Other White House doctors might be willing to flatter their bosses, he writes, and “say that someone was seven feet tall and weighed a hundred pounds”. But his frank approach ultimately enabled the President to ditch smoking – which he did in 2010, after he passed the Affordable Care Act to expand provision of health insurance.

While serving as the Director of the White House Medical Unit, Kuhlman was at the centre of the response to the 9/11 terrorist attacks. He describes giving antibiotics to counter anthrax to those sheltering in one of the White House’s secure bunkers.

“My Department of Defence training had taught me that when terrorists attack, they often also launch a more insidious assault,” Kulhman writes, referencing the possibility of biological warfare.

And he was right: A series of bioterrorism cases followed, involving domestic mail laced with anthrax spores.

Although the care he provided had to accommodate the busy presidential schedule, Kuhlman emphasises that becoming starstruck by famous patients and treating them as “big shots” is a recipe for disaster. “The practice of medicine is built on good information and a solid working relationship based on mutual trust,” he states, “not friendship.”

For me, the key takeaway is the urgent need to carry out cognitive testing of those in office and for those seeking high office

What does Kuhlman have to say about evaluating a president’s physical and mental fitness for office? He devotes an entire chapter to the topic that has exercised many commentators during this year’s race. He looks at the US Constitution, which stipulates: To be eligible to be president, a person must be a citizen by birth, must be no less than 35 years old and must have resided in the country for a minimum of 14 years.

The 25th Amendment to the Constitution adds another layer, addressing the transfer of power if the sitting president experiences death or disability. If a president dies, the vice-president assumes the role. If a president is temporarily impaired, they briefly delegate their powers to the vice-president.

The final section of the 25th Amendment describes how the vice-president and other key personnel can formally declare the president unfit to serve. It has never been activated.

Kuhlman also looks at research findings on ageing and neurocognition, querying how they could fit into the overarching framework of the 25th Amendment. For example, he details how the most important risk factor for cognitive decline is advanced age and how the rate of this decline increases after the age of 60.

As the ages of US presidents edge upwards, how should the potential for cognitive decline be accounted for? Kuhlman says that a president’s physician has a “medical responsibility” to assess potential impairments when appropriate and to communicate about them candidly. Currently, presidential physical examinations do not include cognitive screenings as a matter of course.

As the system stands, Kuhlman notes, the voters are the only true arbiters of who is “too old to rule”.

Transforming Presidential Healthcare provides interesting insights into a pivotal role behind the scenes of global politics. For me, the key takeaway is the urgent need to carry out cognitive testing of those in office and for those seeking high office.

Without them, it’s hard to see how presidential physicians can fully evaluate the health of those they serve.