The adjectives are the most obvious clue. Doctors describe lab results as “normal” or “within normal limits.” If in some rare case these results warranted qualitative assessment, “reassuring” or “encouraging” would be more likely than “excellent.” Were it ever warranted to choose “excellent” as the qualifier, the effect would never need heightening with an adverb like “astonishingly.”

Especially to describe normal lab tests. Many doctors do experience astonishment, but we are trained to keep medical documentation within a regimented, almost militant set of rhetorical boundaries. That serves a couple purposes, primarily to limit subjectivity. During my medical internship, I had a patient who was taking blood thinners, and she came to the hospital after she had accidentally taken too much. Our plan was to keep a close eye on her until the medication wore off. I wrote in the patient’s chart, in one hurried stroke, that the action plan was to discharge her from the hospital as soon as her blood coagulation rates were “cool.”

I received an irate page from my attending physician as soon as he read that. “WHAT DOES IT MEAN FOR A TEST TO BE COOL?”

Point taken, I was supposed to write “when the INR [international normalized ratio] is between 2 and 3.” This way there would be no ambiguity for anyone who reads that chart. He knew what I meant, but his point was that every nurse and social worker and phlebotomist (and lawyer) who picked up that chart needed to be on the same page. So always write this way.

One key place where he does use the right language—“positive results”—he’s using it a way that would be nonsense in clinical parlance. We would say that a test had a positive result, for example, if an HIV assay detected the presence of a virus. Negative results would mean no HIV. Bornstein writes that Trump’s “medical examination showed only positive results.”

Again, in everyday conversation, people would know what that means. Over years of medical training and practice—decades in the case of Bornstein—the instinct to write in a colloquial way is washed out of you. Whether qualitative hyperbole and superlatives would often be of any use in a doctor’s assessment is moot, because they are simply not part of the lexicon. If a physician were going to break from that lexicon, it would not be in a career-defining document when the task is predicated on conveying credibility and authority.

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So for linguistic reasons alone, it would shock me if Bornstein wrote this letter. Add to that the other bizarre elements, and it was jarring to hear him stand by it last week, laughing in the process. In video footage that appears to have been taken covertly, Bernstein also admitted that he “wrote the letter in five minutes” while a car was idling outside waiting for him. This is a critical fact: It means that he cowed to the demands of his patient. (Trump had tweeted two days prior, “I have instructed my long-time doctor to issue, within two weeks, a full medical report—it will show perfection.”)