Tis in my memory lock’d, and you shall keep the key of it. — Shakespeare, Hamlet

Recent events have caused me to think about the use of assessment tools in the determination of a person’s “fitness” for duty.  The use of the Mini Mental Status Exam (MMSE) has long been used to screen for the presence of early dementia. There is another tool, The Montreal Cognitive Assessment or (MOCA) that has been compared to the MMSE as a valid tool for assessing signs of dementia.

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The use of narrow, specific tools of mental function will reveal narrow, specific results. The use of a screening tool for dementia will only show that an individual has no signs of early dementia. That is all it will show. Personality pathology or other mental illnesses will not be demonstrated in such a narrowly focused screening.

If it is our goal to completely assess a person’s true mental state, then a full, psychiatric/psychological evaluation would be in order. A person suffering from depression, bipolar disorder, borderline personality disorder or narcissistic personality disorder would require a full evaluation to get a true picture of their mental state.

We define ourselves by our memories, and feel that we know ourselves by our memory. It is important for us to know that our memories are not all our conscious “holdings”. Memory is conscious, unconscious and somewhere in between. If we all take a moment, we can see it in action. Thinking about something that happened yesterday or a few days ago seems to come pretty easily to most of us. Remembering a trauma is more difficult, and often full of holes. We can remember parts, and suppress others because of the pain they cause. Suppression of memory is both a conscious action and an unconscious action. The use of a memory assessment tool like the MOCA or MMSE will only get at the memories that are not suppressed, and will only show us how the brain is functioning. It  does not show us anything about the mind of the person.

We can, therefore, only say that the brain of the individual seems to be functioning when we look at the results of the tests and not anything about the state of the mind of the individual. I would argue then that taking such a test would not be adequate for the determination of an individual’s fitness for duty or ability to take on a weighty responsibility.

Stephen Taylor, M. D. 

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