When Joe Biden was asked in August 2020 whether he had taken a cognitive test, the 77-year-old presidential candidate interrupted a reporter and snapped, “Why the hell would I take a test?”
Since winning the White House, Biden has continued to dismiss the need for a cognitive exam, and aides have said he has never taken one as president - not in three annual physical exams, and not in the week since a halting debate performance raised more urgent questions about the now-81-year-old’s mental acuity.
That decision has been overseen by a key figure largely unknown to the public: Kevin O’Connor, the physician to the president, who has grown extraordinarily close to Biden since becoming his personal doctor in 2009. A White House official said O’Connor has never recommended that Biden take a cognitive test.
Asked in an ABC-TV interview on Friday night (Saturday NZT) whether he had taken specific tests for cognitive capability, Biden noted that he is regularly seen by White House doctors and responded that “no one said I had to … they said I’m good”.
Unlike some physicians to a president, O’Connor, 58, a doctor of osteopathic medicine and a retired Army colonel, has not appeared at the White House podium to take questions about Biden’s annual physicals and other medical events, including when the president contracted Covid-19 in 2022. He has consistently declined most interview requests, including multiple requests from The Washington Post this year.
Now Biden’s prime-time debate performance - where he mumbled, repeatedly misspoke and sometimes appeared confused - has put new scrutiny on the man that the president simply calls “Doc” and on his handling of the president’s health.
Three of O’Connor’s former colleagues in the White House medical unit, speaking on the condition of anonymity to describe confidential relationships, said Biden’s debate performance suggested to them that the president should undergo cognitive screening.
In addition, Ira Monka, the president of the American Osteopathic Association, who visited with O’Connor at the White House this year, also told The Post that he thinks Biden’s performance should prompt an initial cognitive review to see if more tests are needed.
“Some of the stumbling and missing of the words, whatever was going on, would be a sign to say, maybe this person needs - not maybe - this person should get testing just to rule out the fact that there could be some underlying changes,” Monka said.
Cognitive tests typically involve exercises that gauge short-term memory, attention and other key functions, and can be accompanied by a physical examination, such as gauging a person’s ability to perform rapid movements.
Asked in the ABC interview on Friday whether he would agree to an independent neurological and cognitive exam and publicly release the results, Biden declined, saying, “I have a cognitive test every single day,” referring to his presidential duties. Pressed on whether that meant he wouldn’t agree to such a test, Biden said, “I’ve already done it.”
A number of other people who have worked closely with O’Connor said they were confident that if he saw an indication a cognitive test was needed, he would recommend it.
“He knows how to speak truth to people in power,” said Reamer L. Bushardt, the former dean at the GW School of Medicine & Health Sciences who hired O’Connor in 2017 to work at that institution. “I know he’s someone of integrity that wouldn’t be influenced or driven. And if you ask him a question, he’s going to tell you the truth.”
O’Connor declined through a White House spokesman to answer questions about why he has not administered cognitive tests to the president, even as evidence mounted in the months before the debate of Biden’s increasing struggles. While the White House initially maintained that Biden did not have any medical exams after the debate, Biden later told governors that he had seen his doctor in the days that followed; on Thursday, a White House spokesman acknowledged that Biden was given a “brief check” after the debate for a cold he had been battling, but not a full physical. O’Connor did not accompany Biden to the debate because of a death in the family and was replaced by another member of the unit, a White House official said.
White House spokesman Andrew Bates said in an email that “Dr O’Connor is a world class medical professional” whose “unique expertise is sought across the medical community, in which he is respected for his candour, attention to detail, and work ethic”.
O’Connor’s consultations with Biden, like those of any individual, fall under patient-doctor confidentiality. But the overarching lack of transparency about how O’Connor has evaluated the president’s cognitive health highlights gaps in a system built around entrusting a physician to both safeguard the leader of the free world and to vouch for his health to the public.
The White House medical unit - a team that includes O’Connor and about 50 other military medical personnel who provide round-the-clock monitoring and care for Biden - has been trained for decades to provide reactive care if the president falls ill or is injured, wherever and whenever he needs it. The team is now being confronted by a modern challenge: their patients are increasingly elderly presidents, and White House doctors have never been directed to proactively assess a president’s cognitive health, let alone determine whether that makes him unfit to serve.
The problem transcends political parties; then-House Speaker Nancy Pelosi, Representative Jamie Raskin and fellow Democrats grew so alarmed about Donald Trump, at the time the oldest president to ever first take office, that they sought to set up an independent medical commission to assess the president’s fitness. But that effort was abandoned after Biden won the White House, even though he is three years older than Trump.
While O’Connor has given the public little insight into how he cares for Biden, he provided a revealing overview of his role in a little-noticed conversation recorded at the White House for his alma mater, the New York Institute of Technology’s College of Osteopathic Medicine.
O’Connor said he does not believe that he or other White House physicians should ever prepare for a “great day” at work. Instead, he said he is in the “worst-day-in-your-life business”, in which the president’s health is potentially at stake.
Whatever the White House physician decides to do, O’Connor mused, “literally the whole world is going to second-guess it”.
The ‘bone crusher’
The president and his physician have spent 15 years forging a relationship rooted in their similar origins.
Both men come from a middle-class, Mid-Atlantic upbringing. Both men share a Catholic faith that led Biden to include O’Connor in a small gathering with Pope Francis in 2021, a rare honour for a White House staffer. And unlike some White House officials, both men made their way to the highest levels of Washington without Ivy League pedigrees. O’Connor attended St Bonaventure University on an Army ROTC scholarship before medical school. His Army service included a tour as command surgeon for the Delta Force in Afghanistan in 2001 and in the Iraq invasion of 2003, according to the White House.
In 2006, O’Connor was asked to treat an unnamed patient who had a back ailment. He walked into a room where President George W. Bush was waiting. Bush made follow-up appointments and eventually asked the doctor to work full-time at the White House, O’Connor said. Somewhere along the way, O’Connor’s skill at muscular adjustment earned him the nickname “bone crusher”.
When Biden became vice president in 2009, O’Connor became his personal physician in the White House medical unit and soon grew close to him. “I’ve never had a better commander than Joe Biden,” O’Connor told New York Tech, a publication of his alma mater. “All politics aside, he approaches his craft with such honour. He’s 100 percent ‘family first’. He’s ‘genuinely genuine’.”
The bond between the two men deepened after Biden’s son, Beau, was diagnosed with brain cancer in 2013. O’Connor helped care for Beau Biden, who extracted a promise from the physician as he was wheeled into brain surgery in August of that year.
“Seriously, Doc. No matter what happens. Take care of Pop. For real. Promise me. For real,” Beau Biden said to O’Connor, according to Joe Biden’s 2017 memoir, Promise Me, Dad.
Beau Biden died two years later.
The president has sometimes allowed his physician to override his political instincts, such as when O’Connor in 2015 urged the vice president to cancel a trip to the inauguration of the new president of Uruguay, saying that he was too sick to travel.
“I get it. It’s not good press. It’s embarrassing,” O’Connor told a stubborn Biden, according to Biden’s memoir. “But you know what else is embarrassing and not good press? Collapsing on camera.”
Biden cancelled the trip.
After Trump won the White House, O’Connor decamped to George Washington University, where he worked as a professor and a primary care physician for executives and others. But he continued to serve as the Biden family’s personal physician, declaring in December 2019 that Biden was “fit to successfully execute the duties of the Presidency”.
After his January 2021 inauguration, Biden tapped O’Connor as physician to the president - a role that provides constant access to Biden, giving him extraordinary insight into the president’s physical and mental health.
In the job, O’Connor has taken a more low-profile tack than some of his predecessors. Trump’s White House physician, Ronny Jackson, appeared at the White House briefing room podium in January 2018 and fielded dozens of questions about his experiences treating the president. Jackson also discussed his decision to administer the Montreal Cognitive Assessment, also known as the MoCA test, to Trump and then touted Trump’s performance and broader good health, joking that he could live to “200 years old”.
While Jackson said that Trump got all the MoCA answers correct, Trump has often distorted the purpose and design of the test, bragging about “acing” it and daring Biden to match his performance. The test’s creator has said that there is little utility in using a 2018 test to judge the 78-year-old Trump’s cognitive health today.
When Biden contracted Covid-19 in 2022, answers about Biden’s health were left to officials other than O’Connor, such as White House coronavirus coordinator Ashish Jha or White House spokespeople.
There is no requirement that the president undergo a cognitive test. But there is a long tradition of White House physicians pronouncing the president ready to serve. Biden is “fit for duty”, O’Connor wrote in a February 2024 health summary, with the doctor saying that he had consulted with a neurologist and other specialists.
While Biden has released much more medical information than Trump, neither has disclosed enough to make detailed health assessments, experts said. “We can only see what they want us to see,” said S. Jay Olshansky, a professor of public health at the University of Illinois at Chicago who is the lead author of a 2020 study of the health of Biden and Trump.
After announcing the results of this year’s physical, White House spokeswoman Karine Jean-Pierre defended O’Connor’s decision not to administer a cognitive test.
The issue also came up after a February report by special counsel Robert K. Hur concluded that Biden was a “well-meaning elderly man with a poor memory”.
Biden blasted the report, holding a news conference several hours later to rebut it.
“I’m well-meaning, and I’m elderly, and I know what I’m doing,” Biden said. “My memory is fine.”
No protocols
There is nothing in the 25th Amendment, which deals with how to proceed if the president is disabled or must be removed from office, that spells out the responsibilities of a White House physician or the medical unit, a team first established in 1945. Nor is there formal protocol if a White House physician or other team member proactively concludes that the president is cognitively unwell, according to four former White House medical unit staffers.
The result, said former members of the team and other experts, is a major shortfall in the system protecting the president - a lack of recourse for doctors like O’Connor and his staff should they observe significant problems in a president.
O’Connor would be uniquely well-positioned to notice a decline in Biden’s abilities. The physician works from a White House office and meets regularly with the president, often multiple times per week for “brief check ins”, though not for tests, according to a White House official. While O’Connor is Biden’s primary physician, the team of White House doctors is always on call, including overnight, whether Biden is at the residence or travelling.
The White House medical unit performs frequent drills to prepare for any contingency when the president could be incapacitated, from being wounded in a shooting to suffering a heart attack - or even caught in the vicinity of a nuclear explosion. But former staffers said there has been relatively little effort to prepare for what to do if they think an 81-year-old president is suffering from mental decline. While some high-risk professions, like commercial aviation, have a formalised process where pilots can be grounded until further testing if a physician suspects cognitive impairment, there’s no similar trigger for a president.
One former White House physician said O’Connor and other physicians would likely start by discussing any cognitive concerns directly with the president; if rebuffed, then with a spouse or close family member; and then, with a senior administration official such as the chief of staff or deputy chief of staff.
Some experts and former medical unit officials say that imperative should have grown after Biden’s debate performance. O’Connor’s continued insistence that Biden does not need testing - at minimum to rule out common cognitive problems - flies in the face of the evidence, some experts said, especially for an octogenarian who nearly died from a brain aneurysm in 1988 after delaying treatment while campaigning for president.
(Biden wrote in his memoir, Promises to Keep, that he was told that there was a “significant” chance he would wake up from surgery “with serious deficits to my mental faculties”, but he said that did not happen. Neal Kassell, one of the surgeons who successfully treated Biden, has previously told The Post that the surgeries were successful and that there was no effect on Biden’s mental state.)
Ziad Nasreddine, a Canadian neurologist who created the MoCA test, said he was concerned that Biden “had all these symptoms before the debate”, pointing to prior televised remarks where the president mumbled, misspoke or garbled his words. “It doesn’t seem likely that this is only a transient moment,” Nasreddine added, saying that he believed Biden should undergo cognitive testing.
Jacob Appell, a professor at New York’s Icahn School of Medicine at Mount Sinai who has studied presidential illnesses, said the most recent O’Connor letter in February does not put to rest questions about Biden’s mental condition. While the letter said that Biden passed a number of neurological tests, Appell said “that is not a useful assessment” because it only spells out some conditions that Biden does not have. He said that “if we are interested in finding out the level of cognition, we could do detailed cognitive and neuropsychiatric testing, a full battery conducted over the course of a day” - tests that Biden has not acknowledged having done as president.
Several individuals who know O’Connor said he would put Biden’s health above political considerations. Frank Butler, a former command surgeon of Special Operations forces who has known O’Connor for 25 years and recently co-wrote a book with him about battlefield medicine called Tell Them Yourself: It’s Not Your Day to Die, said O’Connor is “an incredibly principled” person who “has a great track record of doing the right thing”.
Monka, who stressed that he had the highest respect for O’Connor’s capabilities, said he believed the physician “will do the best thing for the president”.
There are strong political incentives for administration officials to not speak up when concerned about the president’s health, a high-stakes decision with career-altering ramifications. But some past White House physicians have battled with political aides over their president’s fitness for the job.
John Hutton, who served as physician to President Ronald Reagan, fought with White House officials in 1985 after they disregarded his warning that Reagan would be incoherent from anesthesia for hours after surgery and instead rushed to restore his powers. The alarmed physician privately called Vice President George H.W. Bush, saying that he was prepared to issue a statement to prevent Reagan from wielding presidential powers if there was an urgent crisis; there was no emergency and the moment passed.
Hutton in a 2004 interview with the University of Virginia said that the situation raised “one of the most difficult questions”.
“When is somebody disabled? Suppose there’s a national threat when somebody is going through one of these things,” said Hutton, who died in 2015. “Who is it who rings the bell?”
Democrats tried to answer that question when Trump held the White House, with party leaders twice introducing legislation that would have established an independent, bipartisan commission of medical experts and retired political leaders to help execute the 25th Amendment. In an emergency, Congress could compel the commission to examine the president and evaluate his or her physical and psychological fitness for the role; if the commission found the president unfit, the vice president would immediately assume the role.
“This is not about Trump … but he shows the need for us to create a process for future presidents,” Pelosi said at an October 2020 news conference.
Pelosi’s office did not respond to a request for comment. A spokesperson for Raskin, who was the lead author of the legislation, said that “nothing has happened” to change his view that the commission is necessary - but that the congressman “definitely does not believe there is any crisis compelling immediate action”.
- Alice Crites contributed to this report