The Peter Attia Drive - #150 - Senator Bill Frist, M.D.： A modern Renaissance man's journey through science, politics, and business

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:00:41.320 now, head over to peteratiyahmd.com forward slash subscribe. Now, without further delay,

00:00:47.740 here's today's episode. I guess this week is Senator Bill Frist. Senator Frist is a former

00:00:55.120 transplant surgeon. He's a pilot, though we don't even get into that in this episode. It's just

00:00:58.860 a whole other amazing story. Obviously, a politician, businessman, healthcare policy

00:01:03.460 expert. I mean, he's truly a renaissance man, as you'll see. He graduated from Princeton and

00:01:08.440 Harvard Medical School, went on to study at Stanford where he learned transplant surgery

00:01:13.600 from the pioneering transplant surgeon of our era, Norman Shumway, before heading over to

00:01:17.880 Vanderbilt where he created the largest transplant program east of the Mississippi. He did that till

00:01:24.600 the early 90s when he up and ran for the U.S. Senate in 1994, having never held public office

00:01:30.840 before. And perhaps even more remarkably than that, he was elected as the 18th Senate Majority Leader

00:01:36.680 in 2002, taking him from the single least senior person in the U.S. Senate to the most senior person.

00:01:43.680 We spend a lot of time talking about his journey through medicine and ultimately 12 years in the

00:01:50.200 Senate through some of the difficult policy decisions and the controversial decisions that

00:01:54.260 were made. Since leaving the Senate in 2006, Bill has done a number of things. He sits on the board of

00:02:01.420 more not-for-profits, for-profit companies than you can count on. Probably spent a decade really focused

00:02:07.920 on private equity before now shifting his attention to more venture-based funding. He also hosts a podcast

00:02:14.960 called A Second Opinion. And we get into about two-thirds of what I had wanted to get into here.

00:02:21.300 That's how much I wanted to talk about. But it's really a remarkable discussion. And one of the most

00:02:25.700 interesting things about Bill that we do touch on here is that in 2005, he effectively called the

00:02:33.220 pandemic. He really laid it out through his experience in studying HIV and creating policy around HIV. He was an

00:02:42.200 instrumental part of PEPFAR, which we talk about as well. And also his experience with the anthrax scare

00:02:49.800 post-9-11. And he basically looked at these examples, coupled with what he saw on a lot of his

00:02:56.480 travel to Africa, which he had done as a physician, and basically said, look, it's not going to be a

00:03:01.660 question of if we have a major pandemic. It's a question of when. And these were the things that

00:03:06.800 needed to be in place. And these are the likely things that are going to happen. And unfortunately,

00:03:10.440 a lot of those things came true and we weren't really ready. So we spend a little bit of time

00:03:14.920 on that. And finally, we talk a little bit about just the current state of politics. And even though

00:03:19.920 this isn't a podcast about politics, I think most people in the current environment can't help but

00:03:24.320 acknowledging that we're in a bit of a strange environment. And we talk a little bit about his

00:03:28.760 optimism as to how things might get better in the future. So without further delay,

00:03:33.880 please enjoy my conversation with Senator Bill Frist.

00:03:40.440 Bill, thank you so much for making time to sit down with me. I know today you had a lot of things

00:03:46.780 going on in your personal life. So I appreciate that we didn't reschedule this, but it would have

00:03:50.980 totally been understood if we needed to. Great to be with you, Peter.

00:03:54.380 By the way, it feels weird calling you Bill. I always feel like I need to call you Senator Frist,

00:03:57.800 but the first time we spoke, you were adamant that I call you Bill. So I'll tell you a funny story.

00:04:01.820 When I left residency, I had such a hard time not calling people Mr. So-and-so,

00:04:06.500 just because, you know, you talk to your patients that way, right? Like, you know, Mr. Jones, Mrs.

00:04:11.100 Smith, we're here to talk about this. And then when I got out in the real world, people were like,

00:04:15.740 you know, you can just call people by their first name. Was that a difficult transition for you?

00:04:20.220 You know, there's two things come to mind. Number one, the most common thing I get, do you get called

00:04:25.520 Senator or Doctor? You know, people who want to be formal. And of course, I say, call me Bill,

00:04:30.780 but that is a harder one because in the Senate, you know, especially today, people are kind of down

00:04:36.620 on the respect world. And Doctor is still pretty much up there. So, you know, I say, well, Doctor,

00:04:43.100 but you're supposed to call Senator, et cetera, et cetera. But then I remember going to Mass General

00:04:48.260 up in Boston, being from Nashville, Tennessee, and being from Nashville, I called everybody out of

00:04:54.180 respect, Mr. If they were two or four years older than me, and it may sound crazy to a lot of people,

00:04:59.760 listen, that's just sort of the Southern way of doing it. And I remember going down and working

00:05:03.060 with a cardiac surgeon and right in the middle of the case, I said, yes, sir. And you're not

00:05:07.180 supposed to say, sir, either. It's kind of like the mister. And then he turned around and said,

00:05:10.380 don't you ever, ever say sir to me again. Isn't that funny? It's just that it depends on where you

00:05:15.860 are. You're exactly right. At what point did you realize growing up that you wanted to be a doctor,

00:05:20.800 let alone a surgeon? You know, I had a real sort of fortunate circumstance in that I was last of five

00:05:27.400 children. And my dad was a family practitioner, a doctor. And my older brother, who was 15 years

00:05:37.100 older than me, went into medicine. So he was a doctor. My middle brother ended up going into cardiac

00:05:42.180 surgery. So he was in this track. And so I pretty much assumed I would go into medicine or nursing or

00:05:49.720 the healing profession from very early on. For that reason, I saw the gratification. I saw the way when

00:05:56.980 dad would come home at night, what he would talk about in terms of healing and giving people hope.

00:06:02.680 So that was just always stuck in my mind. And I thought about other things. And when I jumped up

00:06:08.240 to college, I majored in public and international affairs. And so when I tried other things, I always

00:06:14.560 came right back to the healing profession in some shape or form. So when you were an undergrad,

00:06:20.480 you were not a pre-med. And Princeton's pretty well known for international affairs and things. So you

00:06:25.880 were kind of in the epicenter of where one would go to study such things. But that didn't sway you

00:06:32.760 from medicine. Did it plant a seed that ultimately there would be more for you to do then medicine?

00:06:39.140 You know, in high school and in the early years of college, I interned in Washington, D.C.

00:06:47.820 for Congressman Joe Evans from Tennessee at the time. I spent a summer writing for a newspaper,

00:06:52.160 The Nashville Banner, no longer a daily newspaper here in Nashville. So throughout, it was always

00:06:58.100 being interested in the broader aspects of medicine, of being a doctor. And I had no idea,

00:07:05.300 and I didn't have any master plan with it. But I guess at every stage, and now that I look back,

00:07:10.440 it gets reflected in my life that I always had other parallel interests going on. And as you probably

00:07:16.960 know, and recall, I'm a little older than you are, it wasn't all that popular at the time when you're

00:07:22.660 in medical school to have these other interests, you know, to basically say, well, I want to go

00:07:28.400 write an op-ed on some technology when your professor is sitting there of medicine. And basically,

00:07:34.680 the only thing in the world is medicine. So it was always challenging. And not being in a pre-med

00:07:40.060 tract at Princeton, but still wanting to go to medical school, you know, even the medical schools

00:07:44.760 had a little bit of bias about coming in. At that time, very different today, if you didn't

00:07:49.660 demonstrate working in a lab and all those other pre-med tract things in those college years.

00:07:56.240 And so what was it like for you? You know, Mass General, obviously, is one of the pillars of

00:08:00.160 American medicine. If my memory serves me correctly, isn't Mass General the second oldest hospital in

00:08:04.540 the United States? Or is it the third oldest?

00:08:06.600 Yeah. I don't know. But it's there in the tradition and is all there as well.

00:08:11.980 And so you've got this Northeast training, and then you go way out West for training in

00:08:18.160 cardiac surgery. What was that experience like back? This would have been early 80s that you

00:08:22.740 went out to Stanford?

00:08:23.720 Early 80s. And it's actually interesting in many ways, mainly in retrospect, of course. But

00:08:29.840 I went to Harvard Medical School, and then I did the six years at Mass General and did my cardiac

00:08:35.580 fellowship at Mass General. But when I was just entering that fellowship, it was fascinating.

00:08:41.960 From an ethical standpoint, that the community there had decided, with the board of trustees of the

00:08:48.880 hospital, that they were not going to do heart transplants. And, you know, I'd kind of stayed at

00:08:54.940 Mass General because they'd done the early kidney transplant work in America there, had great

00:09:00.780 immunologists. And then I was, you know, 10 years into this, and then all of a sudden, the board of

00:09:06.600 trustees and the broader community said it's too experimental. It hasn't proven itself. We can

00:09:13.040 vaccinate a million people, I'm exaggerating a little bit, for the cost of one transplant. And

00:09:18.380 therefore, they put a moratorium.

00:09:20.580 Now, what was the mortality at that time? Because Bernard's first heart transplant was in 67?

00:09:25.580 66, 67. It was when Christian Bernard, down in South Africa, did the first transplant. And then

00:09:33.640 after that, there were 100 done in Texas. And then most of those patients died. So it's kind of shut

00:09:38.700 down.

00:09:39.720 And what was happening with Shumway at the time? What was he doing in the 70s?

00:09:43.860 Another fascinating story. And Norman Shumway, who was my mentor at Stanford at the time,

00:09:52.460 was really outside of the mainstream of cardiac surgeons. And you know this, but again, bringing

00:09:57.500 our listeners in a little bit. He had worked diligently for about 10 years in the laboratory,

00:10:04.180 figuring out this heart transplant world, systematically with discipline, not taking it to

00:10:11.100 people until they figured out the science. And then Christian Bernard came in. He watched a

00:10:16.240 little bit of this. He was from South Africa. And more in an opportunist way, he said, well,

00:10:20.240 it looks like Shumway's figured it out. So I'm going to go back to South Africa and do it. And so he did

00:10:24.660 it. Shumway, from that mid-60s to when I got involved in the early 80s, systematically had a program

00:10:32.120 where other programs would do 100 or 50 or 30, like out in Texas, and then they would just leave it

00:10:39.300 totally because the patients died. Well, Shumway would ask the question, why are they dying?

00:10:42.960 He would figure it out. So he was doing about 10 a year or 15 a year and figured out the science of

00:10:48.980 the immunology of it, the cardiac biopsies, the instruments of it, and in a very deliberate way.

00:10:54.540 And I tell that long story because it really had a huge impact on me that the science is really

00:11:02.100 fundamental. It's important. Until you get the science right, you should not be taking this to

00:11:06.780 the clinical world. Know the facts. Get rid of the misinformation. Do clinical trials. Don't

00:11:13.840 prematurely take things to the field. And so at Mass General, they saw a 50% mortality,

00:11:20.240 very expensive procedure of this moving hearts around and the immunology and the equipment that

00:11:26.120 was required. And they said the greatest good for the most people is to not do heart transplants

00:11:32.380 at Mass General or Peter Bent Brigham or Beth Israel or Boston City. To me, from my perspective,

00:11:39.440 I said, are you kidding me? You know, we have the opportunity to, in a very ethical way, figure out

00:11:46.420 heart transplantation in a way that can save hundreds of thousands of lives. If you don't get a heart

00:11:53.440 transplant, you die within six months. If you get it, you can live 10, 15, 20, 30 years. People I

00:11:59.160 transplanted, you know, 28 years ago were still alive here in Nashville and around the country.

00:12:04.220 So I got fed. I didn't get fed up. I did get fed up. But instead of staying at Mass General,

00:12:08.500 I said, I'm going to California to train with this one person in America who systematically

00:12:13.600 had spent 20 years developing heart transplantation and continued to do that because the overall field,

00:12:20.600 the overall heart transplant world continues to evolve.

00:12:23.400 I mean, to me, it's just such an amazing story within medicine to go back to the first transplants

00:12:30.300 within kidney and then to look at heart. And in some ways, liver was almost the most ridiculous

00:12:35.080 of them in terms of the complexity of it. You know, I don't know if you have like a bucket list of people

00:12:39.800 you wish you could have met or interviewed who are no longer alive. And I'm sure you probably met

00:12:45.640 Thomas Starzl. But if I think about people I wish I could have met, Thomas Starzl would be very high on

00:12:50.880 that list. I don't know if you ever read his book, Puzzle People, but I can't recommend it highly

00:12:55.300 enough to people who love stories about the history of medicine. To me, it is, it sounds so much like

00:13:02.020 what you describe Shumway doing, which is systematically in the face of nonstop failure,

00:13:10.280 watching, you know, bad outcome after bad outcome after bad outcome, but in patients for whom there is

00:13:16.000 no other choice. I mean, there is no such thing as an extracorporeal liver. So if a person is in liver

00:13:22.600 failure, they are going to die. There is no temporizing measure. And I don't remember the

00:13:28.020 numbers because it's been so long since I read it, even for the second time. It's a book I've read

00:13:31.620 twice. But I, one thing that stuck with me when I read it, which is one is the belief that you have

00:13:37.840 to have that this is going to get better. And two, just the personality trait that says,

00:13:43.300 I'm not going to get broken by short-term failure after failure after failure, because I'm seeing

00:13:48.840 some other progress. And whether it is, look, we're making strides in the immunology, because

00:13:53.760 back in the early eighties, what was your two, what was your immunosuppressive regimen? I mean,

00:13:58.880 prednisone and MMP, I mean, what, you didn't have much.

00:14:01.740 Yeah. And it comes back and we're seeing it today with today's technology, which is even moving faster,

00:14:07.220 but these great breakthroughs, which require this deliberate thinking in the spite of these

00:14:13.100 challenges that seem insurmountable. There were technological, mechanical ones like doing a

00:14:18.940 cardiac biopsy. All these patients were dying early on because the heart would reject, get inflamed

00:14:24.660 right afterwards. And so then the typical surgeon would walk away from that and say, I'm not doing

00:14:29.320 this. Shumway said, okay, let's figure out the inflammation. So developed an instrument that you

00:14:33.960 can go through the neck into the heart. It sounds terrible, but it's real simple. You can do it in

00:14:38.000 three minutes and figured out how to, to, to address the inflammation, to diagnose it and treat it.

00:14:43.460 And then you, and the medicines that you mentioned when I started in the transplant world and success

00:14:49.700 was not that good early on, it got better, but we were using two drugs. One was called prednisone or

00:14:56.400 steroids that most people have taken or understand. And the other is Imuran. And we didn't have a new

00:15:03.740 drug that came along in about 1982, which is cyclosporine. When you added that drug, which was

00:15:10.700 serendipitously discovered from a fungus over in, I think, Sweden or Switzerland, when you added that

00:15:16.540 to the cocktail, all of a sudden the mortality, which may have been at 50%, went to 20%. Just that

00:15:24.300 one addition, because if you can adjust the immunological treatment and make it where it's not

00:15:30.880 as severe, you don't push down the immune system so much where people would die from infections.

00:15:37.080 But I think the important point in all of this, which I think you're, you're leading and, and I'm

00:15:42.500 sort of feeding into is, is that science is this evolutionary process and that the greats, the

00:15:48.820 Starzl, Tom Starzl, University of Pittsburgh did all transplants, but the world icon leader in liver

00:15:55.200 transplants, which was about two or three years behind heart transplants. And the Norman Shumways of,

00:16:00.800 the world had that deliberate, that discipline, that focused process in taking these insurmountable

00:16:08.360 challenges that were impossible to do and systematically over a period of time, capturing

00:16:13.880 the best of the best, even when there are lots of losses along the way, ultimately be successful.

00:16:19.260 This is just kind of a broader historical question of surgery. When you think back of the last

00:16:24.220 150 years of surgery, the modern era, right? And you think about the giants, right? The Blalocks,

00:16:31.160 the Halsteads, the Shumways, Linehan, Starzl. I mean, these people took, they, they had step function

00:16:39.820 changes in the field, their existence and the teams around them, right? When I, when you talk about a

00:16:45.600 surgeon, you have to talk about the critical care staff, the anesthesiology staff. I mean,

00:16:50.160 no surgeon can do what they do alone, but they fundamentally changed surgery. Do you believe

00:16:56.380 that there are any more step functions ahead in surgery? Are there, are there sort of from a

00:17:02.640 technical standpoint or combination of technology, medicine, instrumentation? Like, is there something

00:17:08.620 that you think is still an untapped opportunity in the way that, you know, you were talking about

00:17:13.840 what Shumway or Starzl did, for example? Yeah. You know, it's good. The transplant world's a dramatic

00:17:18.120 world that, that we've talked about where I would go take a heart out of one person who is brain dead

00:17:25.080 and then replace a diseased heart in a living person totally. And even me describing it is pretty

00:17:32.580 gross. I mean, it's, it's brutal. I mean, you're talking about lifting a heart out of somebody and

00:17:37.060 putting it in there. And I say, yes, I've done a hundred and a hundred times. And then people say,

00:17:41.600 it doesn't sound right. It is amazing though. I mean, it's worth pausing on that for a moment.

00:17:46.080 It is, it's hard to believe. And I haven't participated in nearly as many as you. So maybe

00:17:53.380 it gets old after a while, but I wouldn't, it wouldn't surprise me if every time you did it,

00:17:57.160 it still felt magical. It probably never wore off in terms of what you just explained. It's profound.

00:18:03.480 Never. I think you don't have to have faith really. People will jump to that immediately,

00:18:07.860 but the idea of me getting a call and not me, this is done by everybody. Now at that time,

00:18:13.020 not that many, but now it's done in every major hospital around, but getting a call,

00:18:17.720 flying off in the middle of the night, taking a heart out of somebody, putting it in a bucket

00:18:21.340 with ice around it, and then putting it on an airplane, traveling for three hours, coming back,

00:18:26.880 opening up a patient and spending 45 minutes, put the heart in. It's just like a piece of meat. You're

00:18:31.140 setting in the chest. And then you just step back. And as you warm the patient up, the body up,

00:18:38.440 all of a sudden that inner piece of meat that you've been carrying, it's terrible even to describe

00:18:43.300 it that way. All of a sudden, slowly, that sort of magical moment, it would begin like a bag of

00:18:49.420 worms just kind of moving around. And then bang, all of a sudden it would start beating rhythmically,

00:18:56.800 you know, 70 beats a minute and pumping blood throughout the body. And then that patient goes

00:19:00.900 home a week later. And then, you know, it's, it's miraculous. So I agree with it and you can't fully

00:19:06.700 explain it, but it is, but it took the Shumwais and the Starzils and people like that to do that.

00:19:11.580 And then my generation, which came right beyond that. And then beyond the transplant world,

00:19:16.940 there are other great innovations. You remember where it's, and I don't know exactly when you were

00:19:21.880 doing your surgery, but taking out gallbladders where you see these big incisions and

00:19:26.040 these bloody fields and hip replacements. I mean, all that's been revolutionized through scopes

00:19:32.900 and minimally invasive surgery. So that will probably continue with more robotic surgery.

00:19:38.100 But I think the really exciting things will be at the cellular level of regenerative medicine.

00:19:42.480 Instead of replacing that heart, keeping that old heart in the person, injecting some of the cells

00:19:47.680 in there, understanding what the Human Genome Project delivered to us back in the early 2000s

00:19:52.840 with some manipulation, having those cells that you put in there liven up and energize the dead

00:19:59.920 cells that are there. That kind of breakthrough is going to really be exciting coming forward. So

00:20:05.220 is that surgery or not? I'm not sure. It's, it takes things down to almost the synthetic biology world,

00:20:12.220 which to me is where things are really exciting in terms of at the level of the cellular interaction

00:20:17.900 and, and surgically putting in it, whether it's mitochondria, a lot of the things we're talking

00:20:23.500 about with COVID and vaccines and all today, that's sort of where so much of the future is, I think.

00:20:28.960 So when you got to Stanford, was Bruce Reitz there or had he already left for Hopkins?

00:20:35.520 He was leaving at exactly that time. At that time at Stanford, as you know, there were four cardiac

00:20:42.420 surgeons and Shumway, the cardiac surgeon who was father to them all. Most of the people had

00:20:48.100 gravitated there because of his approach being out of outside of the norm, not a lot of respect for

00:20:54.180 tradition for tradition sake, big believer in team approach. In Boston, you have to work 10 years to

00:21:00.980 get to put in a stitch. You had to wait your time on the East Coast. If you were good at it and you were a

00:21:07.380 first year intern, if you were a fourth year medical student and Shumway saw you operate,

00:21:12.100 he would let you do what he wouldn't let a resident with 10 years of training do if you could do it.

00:21:16.820 So it was more kind of merit based there, all of that approach. And so that was the culture that he

00:21:22.420 built. Huge respect for nurses, huge respect. It wasn't about him. It was about the people around him.

00:21:28.500 He said he was the world's greatest first assistant. And for those who don't follow surgery,

00:21:34.740 the first assistant's the person who's across from the main surgeon who kind of helps the main

00:21:39.620 surgeon do the work. And what he was saying basically, it's not about me. It's about us as

00:21:44.420 a team. And Bruce Wright came out of that tradition and he had just left and of course didn't know him

00:21:50.020 well because he went to Hopkins after that. So you finish getting your, you know, basically

00:21:56.420 your transplant training at Stanford and then you head back to, is it Vanderbilt you go straight to?

00:22:01.700 Yeah. Yeah. And, and you serve there on the faculty for quite some time and you're building

00:22:08.340 a program obviously, right? There was no transplant program. Yeah. You're building.

00:22:12.020 No. Yeah. And at that time we had the Stanford program and there were a few other programs

00:22:17.700 around, but East Mississippi, there were no established real programs. In Tennessee,

00:22:20.900 there was no heart transplant program. So built a program on the model of Stanford and heart transplants.

00:22:26.260 And, and I want to come back to where you're going, but once we mastered heart transplants,

00:22:31.860 this whole field of lung transplants three years later had never been done, never been successful.

00:22:37.220 But because of that drug cyclosporine, we were able to do that.

00:22:39.940 That's what Bruce and Norm did together, right? They did the first heart lung transplant.

00:22:44.740 They did heart lung. Lung, ironically, you have the heart lung, you have the heart lung. Yeah. So you

00:22:50.100 have the heart, it seems like taking a lung would be easier, but it's not. So the combined heart lung

00:22:54.740 where you take them both. And that's what Bruce Wright's and Shumway did. And that's what I brought

00:22:58.740 back to Vanderbilt. Was there any resistance to this given what you just described on the East Coast

00:23:06.420 being kind of a bias towards, hey, this is still very costly on a cost per life basis. There's

00:23:12.820 probably more efficient things that we can do with resources. Nowhere in this have we talked about

00:23:17.380 where insurance companies are. How are insurance companies thinking about this type of a procedure

00:23:23.220 at that time? It was interesting. So insurance and the payers, you have Medicare, government,

00:23:28.260 Medicaid, and then you have the commercial payers. At that time, it was still investigational. So

00:23:34.100 Medicare, our government did not reimburse for transplants. It was regarded as experimental

00:23:40.260 for about eight years. And they did a very smart thing. They designated certain centers to figure it

00:23:47.220 out. And then once the survival was sufficient and you were qualified as a center of excellence,

00:23:54.420 then they would start reimbursing you. The payer system was a little bit the same thing. And I was,

00:24:00.100 again, lucky and I wouldn't have come to Vanderbilt if it hadn't been that far,

00:24:04.100 sort of thinking ahead. They basically said, Bill, to get the program up, you've done,

00:24:08.980 you know, scores and scores of heart transplants. You were trained by the best.

00:24:12.900 For your first 10 transplants, because we know this is just the opposite of Mass General,

00:24:18.740 we know this is lifesaving to thousands and thousands of people dying across America. We also

00:24:26.340 know that it's not 99% successful. But what we'll do for your first 10 transplants to get your program

00:24:32.660 up and running, we will cover you if the insurance does not. And so that gave me enough to, and we

00:24:39.220 did maybe six and then it started being reimbursed. And then over a period of about eight years, every

00:24:44.180 commercial payer, Medicare and Medicaid began to reimburse because they had the outcomes. 100%

00:24:50.980 mortality. Everybody would die who needed a transplant. Everybody would die within six months without it.

00:24:56.500 And if you got it, you on average, 80% of the time would live at least five years. If you got beyond

00:25:01.780 that would live 10, 15, 20, or 30 years. What was the pressure like on you during those first

00:25:08.420 transplants? I mean, here you are, it's one thing when you're at Stanford and you're under the umbrella

00:25:13.460 of Shumway and this incredible environment he's built, which as you said, you've got the best

00:25:18.900 anesthesiologists, you've got the best nurses, you've got the best perfusionists, like everything that is

00:25:23.540 needed to support that program. You have the best of, and the culture is already there. And you're a

00:25:28.500 fellow within that system. And now you have to go out and hang your own shingle and you have to now

00:25:34.900 train everybody to do what you took for, I'm not saying you took it for granted, right? But what one

00:25:39.540 could have easily taken for granted at Stanford. And all of a sudden, now you're the operating surgeon.

00:25:45.940 You don't have Shumway first assisting you. And you don't have a lot of time to figure this out. You can't

00:25:52.100 take 50 transplants to get it worked out. Do you remember what those first few days were like? I

00:25:57.540 mean, that must've been unbelievable stress because it's two stresses. It's the obvious stress of,

00:26:03.380 I got to save this person's life. But there's even, there's a bigger thing at stake, which is

00:26:08.820 enough bad outcomes and this program gets shut down. And we don't know what that means for the

00:26:13.220 future transplantation. Yeah. And there was an additional burden that at that time,

00:26:19.460 Shumway was training the great cardiac surgeons. They weren't great. They were young people like

00:26:24.020 me at the time. But just like Bruce Reitz, who we talked about, he didn't send them to Hopkins,

00:26:30.500 but Bruce came out of this very interesting culture where team was very important, where humility was

00:26:38.100 very important. That's juxtaposed the way most people think about cardiac surgeons who are in there,

00:26:43.620 you know, high pressure type A, throwing instruments. You never saw that. And so when

00:26:48.500 I came to Vanderbilt, east of Mississippi, Bruce was up in Hopkins. All of a sudden, all over the

00:26:54.020 country, people said, why don't we go to these guys instead of going out to California? So all of a

00:26:59.380 sudden, within a year of me being at Vanderbilt, starting a program from scratch, I was getting

00:27:04.740 referrals, you know, hundreds of people coming in saying, I want the Shumway approach. Shumway says,

00:27:09.860 you know, you're as good as he is. You know, that's the way he would talk coming in.

00:27:13.860 But to answer your question, and it comes back to what I threw in about Shumway saying he was the

00:27:18.420 best first assistant. I came here and there was a guy by the name of Walter Merrill. Walter Merrill

00:27:22.980 was Hopkins trained, excellent surgeon, pediatric surgeon, adult surgeon. He could do it all. He was

00:27:29.940 gifted, the most humble person in the world. And Walter had come out to Stanford to watch me

00:27:36.420 operate to kind of learn about the program for Vanderbilt. And so we had this dialogue. And

00:27:41.220 from day one, for the next 10 years, there wouldn't be a transplant that we did. And we did hearts

00:27:46.900 and heart lungs. And we did lungs. We did infant transplants. We were transplanting kids

00:27:51.540 or babies at two days of age and three days of age. There was never a transplant that I was involved

00:27:56.980 with that Walter Merrill wasn't there. Link, side by side, sort of this alter ego. And with that,

00:28:04.420 and building the team with nurses and perfusion is to sort of share this same Shumway mentality of

00:28:11.380 team first. Keep it simple, stupid. Don't be afraid to double dribble it. If you don't get

00:28:16.260 it perfect the first time, go back and do it again. And it's worth saying all that a little

00:28:21.220 because I want to jump ahead a little bit because that program after I left has continued to grow

00:28:27.940 10 years, 15, 20 years later to where that program today is the largest heart transplant program in

00:28:34.100 America. It does more heart transplants than in any center that people are, you know,

00:28:39.140 listening to us in their cities today. And it has nothing to do with me really, but it's taking

00:28:43.700 that experience, which again, you understand that what the residents experience is and the young

00:28:49.140 faculty is, if you're lucky enough to have a mentor, you can capture that culture and you go out and

00:28:54.980 apply it. So I replicated exactly what I saw at Stanford to get it up and run in those first two years,

00:29:00.420 worked with a great team. And then with that, we were on the cutting edge of the early lung

00:29:06.100 transplants, the early heart lung transplants. And then ultimately, obviously we added liver to it

00:29:12.020 and we had bone marrow already. We added pancreas and became a large multi-organ transplant center.

00:29:17.460 Now, where was DeBakey and Cooley in the midst of this? When did the big Texas centers participate?

00:29:24.740 They were early and it fits with Texas. And they were great surgeons. As you know, they are up there

00:29:31.620 and they would say they're above Starzl and Shumway just because their egos were big.

00:29:38.580 And they were excellent surgeons. And they did these incremental leaps in surgery and

00:29:44.260 in vascular surgery. Both of them, they're in the same town in Houston, Texas. And they, which fits with

00:29:50.420 the ego, the confidence and ability jumped on transplants as soon as Shumway did the first one

00:29:56.100 in America. Christian Bernard did one a few months later. Shumway did one. And then Shumway was going

00:30:00.820 to continue along 15 a year, the way he was doing it. Deliberate, let's learn, iterative process.

00:30:06.500 But DeBakey and Cooley said, well, listen, this thing looks pretty good. It seems to work pretty well.

00:30:11.140 And so they did it in Texas. And this was all in the late 60s. So remember, this was all 67, 68.

00:30:17.300 And between 68 and about 69, they did, I think, 110 heart transplants in competition with each other,

00:30:23.460 do it big, do it Texas style. And then all those patients died. And they died, which comes back to

00:30:28.980 the story. Shumway was out there figuring out how to treat the heart rejection, this inflammation using

00:30:34.340 that little cannula he puts through the neck. And they didn't have the patients for that. And so they

00:30:40.100 shut their programs down and went on to other things. And then in the late 70s, started doing

00:30:46.420 a few. And then the 80s kind of picked up where everybody else did. I mean, the whole story of

00:30:50.580 DeBakey and Cooley, I don't know if there's a book about it, but if there is, I'd love to read it.

00:30:54.740 The rivalry between them is unbelievable, right? I mean, it's two legends in cardiac surgery,

00:31:00.100 both of whom will tell you that they're the greatest of all time. Did they ever reconcile before

00:31:05.060 DeBakey? I think DeBakey died first, right? Yeah, they did. And their hospitals were right across the

00:31:09.700 street. And never did, really. I think when DeBakey or Cooley got a Medal of Honor that there

00:31:17.220 was some kind of congratulations that went on, but in essence, never did. Yeah, it's interesting. I

00:31:22.980 never met DeBakey, but I met Cooley because he trained at Hopkins. And so every night when you're

00:31:28.020 on call, when you'd be walking through the Blaylock hallway, Hopkins is such a storied place. There's

00:31:33.860 never a piece of tradition that's not enough, right? And you'd see these pictures of the young

00:31:38.240 Denton Cooley and he was just upsettingly handsome, right? So sure enough, we're at the

00:31:44.080 American College of Surgeons one year and each, as you know, every university or every medical school

00:31:49.520 has their own thing. So you'd go to the Vanderbilt one and you'd probably go stop at the Stanford one

00:31:54.520 and you'd go stop at the MGH one. And so at the Hopkins one, Cooley shows up and I'm there with

00:32:00.400 my closest friend from residency who happens to be a cardiac surgery fellow about to go and embark on

00:32:05.680 his pediatric cardiac fellowship. And Cooley was talking with both of us and he says, oh,

00:32:10.000 what year are you in? And I think I was in my third year or something. And he says to my friend,

00:32:14.180 Jorge Salazar, what year are you in? And Jorge says, well, I'm in my ninth year. Cause that's,

00:32:18.820 you know, at the time, by that point, it's nine years just to do adult cardiac surgery.

00:32:22.820 And then he said, and then you're going to go off and do pediatric cardiac, I think is another two

00:32:27.200 years at UCSF. And he's like, gosh, that's just unbelievable. I mean, back in my day,

00:32:32.440 it only took six years to become a cardiac surgeon. Now, admittedly, I was better than

00:32:36.840 everybody else and blah, blah, blah, blah. But he said it completely seriously. Like there was no

00:32:41.700 irony in that statement. And we got such a kick out of that, but I guess there's some truth to it. I

00:32:46.440 mean, he was a gifted surgeon. Yeah. And he's really, they're icons and contributed so much. And

00:32:51.520 they're, you know, hundreds of thousands of people alive today because of people they've trained and

00:32:56.080 procedures they've done and really amazing icons in that field of cardiac surgery. They probably,

00:33:01.500 they won't ever be anybody like them again. And cardiac surgery has changed so much. It's one

00:33:06.760 of the reasons, but, but they were just two talented prodigy type surgeons.

00:33:11.720 Do you think that, that medicine can no longer attract that caliber of individual? Like has the

00:33:19.340 profession changed such that the best and the brightest would never consider medicine today?

00:33:25.340 I'm not close enough to what a, what the hotshot college kid is doing today, but, you know,

00:33:30.060 given for example, the incredible changes we've seen in technology, is it really, you know,

00:33:35.320 the case that the, the coolies and the debakeys and the shumways of the world, if they were 20 years

00:33:40.420 old today would be going to Silicon Valley or would be going to Boston and going into biotech startups.

00:33:46.440 Like, you know, there are other ways to serve people that don't involve literally going into

00:33:51.180 medicine. And I, do you ever think about that? Like, is there, is there, has there been

00:33:55.200 some sort of passing of the torch in terms of the war for talent?

00:33:58.740 You know, when you think of the Starzils, the debakeys and shumway and the great surgeons,

00:34:05.760 you think of great athletes. You think of the athletic part of it and part they're using their

00:34:10.680 hands. They want you, you got to be fast, deliberate. You got to keep it simple. You got to

00:34:15.540 be right. And I think because of technology, that's less important. I think the fact that we're

00:34:23.400 operating through telescopes and soon microscopes, when you asked your earlier question, that the

00:34:29.240 sort of athletic, competitive, hero on the field, cowboyish sort of approach, I think we're, we're

00:34:36.880 beyond that. Just to most of the big sort of blood and guts, that kind of imagery is passed by.

00:34:44.880 But to go back to your question, no, I think medicine still, and maybe in some ways even more so

00:34:51.800 because we've opened up this whole world of biology, synthetic biology, and at the cellular

00:34:56.840 level, the regenerative medicine and the use of stem cells, all of these things are going to attract,

00:35:03.300 and they're going to be, they're going to go in as medicine because they want to heal.

00:35:06.980 They want to be a part of something bigger than themselves and not just behind a microscope

00:35:10.880 that I think it's going to continue to attract great, great people. And if you look at,

00:35:15.740 at least here at Vanderbilt, where I'm familiar with medical school applications,

00:35:19.020 they're at all time high right now. And people say yes, but the quality is not there. And the

00:35:23.760 attraction of making a lot of money or doing the next Uber or Airbnb is out there. I think all of

00:35:29.700 that's right. But I think we're going to continue to see and maybe even see an increase in the overall

00:35:37.340 quality of people applying to medical school and then going to medical school and then entering

00:35:43.140 these fields.

00:35:44.300 I'll ask you the question I get asked all the time, and I think you can answer it with, frankly,

00:35:48.840 a far better lens, which is, what advice do you have for somebody today who wants to go into

00:35:55.480 medicine, doesn't quite know how they want to do it based on all you've seen and what you see in the

00:36:01.360 future, in the landscape? And now we're getting ahead of ourselves because we haven't got to this

00:36:05.220 part of the discussion where we're going to talk about policy and things like that. But given what

00:36:08.800 you know about the profession of medicine and also the landscape of payers, hospital systems,

00:36:16.260 consolidation of these things, at-risk versus not-at-risk reimbursement, all these things,

00:36:21.860 what do you say to somebody? Do you say, go forth and conquer? Do you say, you know,

00:36:25.520 here's a hedge that you want to have in place? I mean, what advice do you have for somebody to be

00:36:28.880 successful?

00:36:29.880 You know, where you started is probably still my philosophy, and I'm still active in teaching

00:36:35.520 here and mentoring a lot of people in medicine and health. And I think staying broad, I kind of fell

00:36:44.300 into that because I knew what my track was going to be in medicine, and therefore I wanted to do

00:36:49.000 journalism. And I wanted to try the policy world and wanted to go to Washington and wanted to write

00:36:55.200 about technology all at the time I was going to medical school. Then it was harder, as we said,

00:37:00.180 because there was a stigma almost against it. And today, I think the professors in medical school

00:37:06.280 understand that the best, whether it's on the social side or even on the technical side,

00:37:12.700 the best are people who bring broad experiences, have the curious mind that isn't narrowed down to

00:37:19.280 just one area, to, you know, just cardiac surgery or just bypass surgery or valves, but has that

00:37:26.640 curiosity throughout life. So I'd still continue to encourage people to live as broadly as possible,

00:37:32.840 to develop those interests, to look for your talents. And if they're outside of medicine,

00:37:37.180 figure out some way, either as a hobby or something on the side, or write an article every week about it

00:37:43.840 to keep that going. And I guess because I have jumped around so much and kind of changed career

00:37:48.760 every 10 or 12 years, that I see how, in truth, it's all the same thing. It's all health, and it's all

00:37:55.000 healing. It's all giving hope. There's lots of different ways to do it. Let's fast forward a

00:38:00.700 little bit to call it the early 90s. Do you have a sense at this point that you want to make a run

00:38:06.280 for Senate? Or how were you starting to think about a transition into elected office? It's interesting.

00:38:14.040 My goal was never to be in the United States Senate, ever, ever, ever. And I'd spent right at 10 years

00:38:20.880 learning all this surgery and medical school and how to do transplants and how to do surgery. And

00:38:26.080 then about 10 years here at Vanderbilt. And we built a transplant center, a multi-organ transplant

00:38:31.820 center that was a great foundation for the future. And then I just began to ask myself, I did not serve

00:38:38.100 in Vietnam, which a lot of people just right above me had done. I'd not been in the service. I'd not

00:38:43.300 done anything actively other than learn to be a doctor. And, you know, spent 18 hours a day doing it

00:38:48.860 for those years. And I said, given that I was running a large transplant center and doing a lot

00:38:55.820 of good, I felt, what would be the one other thing that one might do to affect health, maybe not of an

00:39:04.780 individual, but health of a community or health of a population? And I said, well, you know, do you go

00:39:11.360 run a university? I'd been on the board of Princeton University as a young alumnus and sort of saw the power

00:39:17.660 there. And I thought about that, no, because I just don't think I could reach quite enough people.

00:39:22.820 And so I systematically eliminated, you know, doing anything. I knew policy could do it because

00:39:28.640 policy could affect the world. And I'd seen that back 20 years before when I'd been an intern during

00:39:34.120 the college years. And so I said, the only place is really the United States Senate. I have a job.

00:39:39.880 I know what I can do. But if you could get to that position, not to change health care necessarily,

00:39:46.840 not to, at the time, it was Clinton care and all sorts of political issues. And it really wasn't

00:39:52.380 for that reason. It really was an extension of what I saw as a little boy when my dad would come home.

00:39:58.920 And that was in the days he had doctor's bags. And he would sit down exhausted and say, you know,

00:40:03.220 the greatest gratification has been able to give somebody hope. And all of a sudden,

00:40:08.020 I said, policy can do that. And so I jumped. And nobody in my family had ever served in public

00:40:12.840 office. Nobody had run for public office. They were not overly partisan. My mom was probably more

00:40:19.860 of a Democrat. My dad was probably more Republican. And I was probably neither. You know, I was just

00:40:24.680 out there doing heart surgery every day. So it really was an extension of that earlier pull,

00:40:30.440 probably genetic in some way of wanting to serve and that being a way to serve a population. And,

00:40:37.520 you know, it sounds kind of patting yourself on the shoulder now in retrospect, but that was what

00:40:42.100 was going through my mind. And I didn't have anybody to look to. My dad said, are you crazy? And he's no

00:40:47.160 longer alive. He died 20 years ago. But he said, you know, you're at the top of the world in surgery

00:40:53.340 and innovation and running a large laboratory and writing papers. And, you know, why would you leave

00:40:58.780 that to go into this world of policy? And the answer then was what it is now. I also said,

00:41:04.360 I wasn't going to stay forever. I said, you know, I'm not a politician. I love policy and I want to

00:41:09.440 affect change and I want to innovate, but I only want to go do it for 10 years. And that's how I took

00:41:16.780 the leap. The Senate is the highest piece of Congress. So to, you know, I could, it's almost easier to

00:41:23.080 understand if you said, look, I'm going to go run for the House of Representatives. I don't know

00:41:25.620 how many, how many seats are there on the House of Representatives in Tennessee? Nine. Okay. But

00:41:30.620 to sort of say, I'm going to be one of the two people running for Senate is kind of remarkable.

00:41:35.480 How long of a process was that? So the election was 96. When did you have to get serious about this?

00:41:41.720 Is this like a two-year process, a one-year process? I spent a year and a half. I had to leave. I didn't

00:41:47.600 have to leave, but you either do it or you don't. And this is the advice I give people. If you're

00:41:51.900 going to get, go all in. So probably about two and a half years before I started talking,

00:41:58.960 the problem I had is my parents didn't really buy into it. My family really didn't because it's kind

00:42:06.100 of hard to understand. So who do you talk to? And there hadn't been a physician elected to the United

00:42:14.040 States Senate. 100 people, two from every state. There hadn't been a physician elected to the Senate

00:42:21.460 since 1928. So I didn't have anybody to call or go see who'd gone through this eye of the needle

00:42:28.020 medical school and internship and residency and fellowship and practice. And that made it hard.

00:42:35.100 And maybe that was a good thing. They may have said, you know, get out of here. Don't do it.

00:42:37.760 But that was hard. And so I systematically took about a year. This one, I'm still practicing.

00:42:45.100 And I went to see Howard Baker. He'd been majority leader of the United States Senate before. A

00:42:50.400 centrist. I went and talked to Lamar Alexander at the time who had been governor, but he hadn't been

00:42:55.840 in the Senate. I ultimately recruited him around for the Senate and went and talked to Al Gore at the time

00:43:00.780 who was a senator and had great conversations. And my fundamental question was, am I right? Or is

00:43:06.600 this just like, you know, dreams? And to the one, they said, it's a tough business. Half the people

00:43:14.420 are going to hate you all the time and half are going to like you. And it's going to be very different

00:43:18.900 than medicine. But if you're really serious about it, you ought to do it. Howard Baker, who was just an

00:43:25.160 amazing guy. And again, he was also from Tennessee. He, the first time he didn't listen to me very much

00:43:30.180 or he politely did. The second time, you know, politely. And then about the third or fourth time

00:43:35.080 I went to see him, he finally said, OK, you must be interested and go ahead and make the jump.

00:43:40.740 I mean, you're having a chance to speak with Al Gore when he's the vice president at this point.

00:43:45.040 No, he was still, he was right during that period of time. And that was going to open up a seat

00:43:49.340 actually in Tennessee at the time. He was still in the Senate because this was in the early 90s.

00:43:55.060 Oh, this is before 92 then even. Wow.

00:43:57.000 Exactly. And this is all 91. And then ultimately that seat opened up and then I had an option of

00:44:03.260 running for that seat, which is an open seat is easier to win because you've got two people in

00:44:08.260 there that nobody knows. And it's sort of a flip of the coin or the other seat. And I don't know

00:44:14.260 exactly why, but I went the less traditional route and challenged an incumbent. And I know why,

00:44:21.860 because I was the fresh face and he was the person who'd been around for 18 years. But it was

00:44:26.580 unconventional to go that route at the time. So you ran in 94 against the incumbent. Is that

00:44:32.900 correct? Yeah. And you won by a pretty hefty margin, correct? Yeah. And that was, I had a primary with

00:44:40.040 six others. Yeah. I was going to ask you about the primary. What was the primary like back then

00:44:44.420 compared to, for example, what primaries are like today, which is a fight to the extreme?

00:44:49.060 Thank goodness it's not today where people get pushed out. Tennessee until recently, and it's

00:44:55.740 changed in the last four years, but until recently, Tennessee had produced senators that were in the

00:45:01.160 center. The eastern part of the state was more Republican. The western was more democratic. The

00:45:05.900 middle where I live was sort of in the middle. So if you were versatile enough to move through that

00:45:10.640 state, your politics tended to be very principled, and it might be principled Democrat or Republican,

00:45:17.760 but you're pretty much going to be appealing to a broad range of people. So in our primary,

00:45:23.200 there were six people all out of that same ilk. My disadvantage was that I was an outsider.

00:45:29.220 I hadn't played my political dues with the Republican Party. Number one, I was from middle Tennessee

00:45:33.880 and not East Tennessee. And then that was it. So, but the race was very different. And in that,

00:45:40.440 the primary, just interestingly enough, was the person who I ultimately recruited to the United

00:45:46.940 States Senate, Bob Corker. And Bob Corker and I, he was an outsider and I was an outsider. He and I

00:45:52.220 were in the primary. So it started at six, came down to two. All races are tough races. You always say

00:45:57.080 that ours was a clean race and ours was a hundred percent cleaner than these races today, but it's

00:46:02.840 all just hand-to-hand combat, this politic stuff. And so I don't want to over-idealize the way it was,

00:46:08.680 but we were out of this extreme sort of polar opposites where in a primary, somebody's driven

00:46:15.020 to the, to the either extreme right or extreme left. Do you remember what the main policy issues

00:46:22.140 that you were running on in the primary and then ultimately in the general that year in 94?

00:46:26.780 And that comes with other things. So, and because ultimately one, which nobody had expected,

00:46:31.820 nobody, chances were probably one in a hundred. And the other thing that did happen, that it didn't

00:46:38.600 start that way when I jumped in, but at the end in 1994 ended up being a lot of Republicans coming in.

00:46:46.040 So I was part of that wave. I was still the least expected. I was the only person to beat an incumbent

00:46:53.060 United States Senator who came in. And so ultimately one, but there was the luck end of it being at the

00:46:59.380 right place at the right time as well. And so the policy issues, ironically, when you look at today

00:47:04.780 were balance the budget. Over time, eliminate the debt, keep taxes small. So those were sort of the

00:47:15.240 big issues. These big physical issues that were out there. Welfare reform, which just talked about

00:47:22.860 in that period of time, ultimately the bill passed about three or four years later, but those were sort

00:47:27.340 of the three big issues. And just to go back to the first point you made, what you're really saying

00:47:31.800 is, look, in 94, two years into a president's term, the opposite party generally has a tailwind at that

00:47:40.880 first midterm election, correct? That's correct. For example, I remember in 2010, two years into

00:47:47.000 Obama's term, you get a little bit of that tailwind for Republicans and vice versa. So this in 94 was the

00:47:53.240 same thing. Now, how did you learn the mechanics of the U.S. Senate? I mean, I got to tell you, I find this

00:48:02.460 stuff really interesting, Bill, just in part because I grew up in another country and I have an inferiority

00:48:09.360 complex. Like I didn't learn U.S. history growing up. So you asked my daughter, she's like, Dad, why are you

00:48:14.780 always grilling me on U.S. history? And it's like, hey, I'm trying to learn this stuff with you. But oh my God,

00:48:20.440 I'm trying to figure out what the whip does versus the minority leader versus this and what, you know,

00:48:24.980 what this means in this bill versus that. I mean, it just strikes me as when you go straight into the

00:48:30.920 U.S. Senate, that's like going straight into the major leagues, never playing AAA, AA, and Little

00:48:36.720 League baseball. Like how do you learn all of that stuff? I mean, was that the scary? I mean, if the

00:48:42.840 first time you're doing a transplant by yourself is scary, I would think the first day you're sitting on

00:48:47.060 the floor of the U.S. Senate is 10 times more scary. Yeah, it was, I guess when I was first

00:48:54.100 running, I didn't know if I'd win or not. And then about a week out, I felt it, that I knew I would

00:49:00.500 win. So that, the worst part with the first, the November to January equivalent 22nd or January 4th,

00:49:07.720 not knowing what all this is about. The Senate doesn't have a Robert Rules of Orders. There's not

00:49:13.480 a book you read. There's a little book of rules and you'll hear, you know, you hear about it every

00:49:19.640 two years. They have to pass the rules. But it's like a 30-page book. The real book is precedent that's

00:49:26.800 set. And precedent is experience. It's being around. It's age. It's knowledge. It is, you know,

00:49:33.940 all the other stuff that I had is zero. You gave me a 30-page book, you know, it's like it, like in

00:49:40.040 medicine or going to a new rotation in your residency. You know, you just hop in and do it.

00:49:44.420 And you do it fast and you do it hard. And you may do it for a month and you'll have to switch the next

00:49:48.020 month. So that would have been easy. The challenge of the Senate is that it's not a book that you can

00:49:53.000 read. And I had the disadvantage of not having anybody I knew in the Senate either. No friends,

00:49:58.880 no sort of colleagues. In retrospect, that's all a real advantage. I was able to come in as an

00:50:04.480 outsider as a physician. Somebody who is looked at to be trusted. Somebody that is looked at to be

00:50:10.880 fair. Somebody who learns predominantly, not the way a typical politician does, is that I know better

00:50:17.320 than you. It's, I got to listen. If the patient comes in the door, which I had done for the previous

00:50:24.020 20 years, I want to size them up. I want to listen. I want to look at the body language. I don't want to

00:50:29.040 say anything until they give me that chief complaint or that last, you know, look or question

00:50:34.960 as they go out the door. And all of that, which is second nature, it's part of being a physician or

00:50:41.500 being a healer or a nurse is that listing, that empathy component is part of the culture, but really

00:50:49.280 the being. It is in the DNA of physicians and nurses and counselors and healers. The room I walked

00:50:56.060 into had 63 lawyers, 63 lawyers. I walked into that chamber and, and that chamber, every chair was

00:51:04.220 full with somebody who had for 10 years had been arguing legal cases and, and all. And so you'd say

00:51:09.500 that's a disadvantage. Again, it ended up being a pretty big advantage and I didn't realize it at the

00:51:14.700 time, but by listening very carefully, by working with trust and upholding that trust, because I came

00:51:21.000 in with this image and the reality of being a physician, people would come to me and they'd say,

00:51:26.560 what do you think? And you know, how, what is your look on this from the outside? You've been around

00:51:32.360 patients every day, 20 different patients every day for the last 20 years of your life. And you've

00:51:37.800 listened to them. You know, I've been in the United States Senate, about as far from real people as you

00:51:42.480 can get. And so all of that came as real advantages. And again, I didn't know it. There hadn't been a doctor

00:51:48.740 there. I told you since, you know, 1928 or elected since 1928. So that was it. And kind of stuck with

00:51:54.880 that throughout, but it, it wasn't the healthcare issues when there was a healthcare issue. It would

00:52:00.360 all come to me immediately because the time healthcare was probably, I don't know, 16% of

00:52:07.100 our economy. And yet there was nobody in the chamber who'd ever taken care of a patient or written a

00:52:12.540 prescription or been involved at all. And so that kind of information gravitated toward me as well.

00:52:18.740 You know, you mentioned that 63% of the Senate were lawyers, 1% physicians. It's probably a dated

00:52:28.040 statistic. So I don't know what it is today, but I can't imagine it's far from this. But the last

00:52:33.260 time I looked at the stats, when you looked at the entire Congress, both the House and the Senate

00:52:39.000 combined, slightly less than 1% had any training in secondary education. So whether it be an undergraduate

00:52:45.560 degree in science or an advanced degree like yours, why do you think that is?

00:52:50.940 Well, you know, it's interesting. And then right now there are three physicians in the Senate.

00:52:56.940 And so I kind of broke the glass ceiling and that's been three or four. And in the House are 14.

00:53:02.380 So it's clearly more than what it was when I...

00:53:04.400 So it's more. But if you look at historically and you sort of start now and go backwards in 50-year

00:53:10.840 increments, and I won't exaggerate, but I'll give you just the image. In the first 50 years of our

00:53:15.780 country, the sort of 17, sort of 50 to 18 or 1810, there were, I think, like 25 or 24 physicians in the

00:53:25.600 Senate over a six-year period in and out. If you look at the next 50 years, 1800 to 1850, it was 12,

00:53:32.020 about half of that. And if you look at 1850 to 1900, it was about half of that. And then 1900 to

00:53:38.060 1950, it was about half of that. So it got down to one. So it hadn't always been that way. But over

00:53:43.740 time, as medicine got more specialized, as some of the stigma that we talked about earlier, that,

00:53:51.480 you know, if you're in medicine, even if you could look at policy with the AMA, the American Medical

00:53:56.660 Association, you're not a serious doctor. That was kind of the stigma. So people were discouraged.

00:54:01.560 And then doctors wanted to focus on their work. And therefore, they didn't put themselves out

00:54:06.880 there. And then even after I got there, you know, physicians don't support the political system that

00:54:13.660 much. They don't get involved in policy or politics. And I think it's been to the detriment

00:54:19.280 of patients in America, because physicians are the best voice for 300 million people, because they're

00:54:27.540 listening to their problems and their challenges and the socioeconomic and the diversity issues.

00:54:33.260 And so they should be more interested. And so I don't think it's really that the body itself had

00:54:40.040 aversion to them. It's really that people from the science world didn't move in that direction.

00:54:45.560 And there are good reasons not to. I mean, it tears your life apart. I mean, you give up all your

00:54:50.440 privacy. Families are destroyed. You have 50 percent of the country hating you, not hating you,

00:54:55.960 exaggerating, but. Well, certainly today. Today, you really do. So I can't fully explain it,

00:55:03.020 but I can tell you what the sort of issues that that we are confronted with today and the issues

00:55:09.260 that I ultimately, you know, even my 12 year period we addressed. I was not the lone voice,

00:55:15.240 but I spent a lot of time explaining what science is. And as science was progressing and technology was

00:55:21.260 progressing, ethical issues were involved. They would gravitate naturally to the person sitting

00:55:27.400 next to you if they happened to be a doctor on the, on the chamber floor. There'd just been too few of

00:55:31.460 them, I would say over time. When you think about that first term in the Senate from 94 to 2000,

00:55:37.740 you alluded to it earlier. You came into this saying without any ambiguity, you were hoping to serve

00:55:45.960 two terms in the Senate, not a day longer, and you were never going to seek higher office thereafter.

00:55:51.620 Why were you so confident to make that assertion? I mean, most people who would serve in the Senate

00:55:57.540 would want to maybe keep their options open and say, you know, look, maybe if things go well,

00:56:02.280 there's, I'd stay for a third term or I'd seek higher office. Why were you so adamant about this

00:56:07.120 12 year limit? Yeah, I actually told the people of Tennessee, 7 million people, I'll serve for 12

00:56:13.460 years. I've got a job. I believed very much in a concept called the citizen legislator.

00:56:20.560 The concept that somebody goes, it's at the federal level that goes, they leave their home,

00:56:27.080 they leave the people, they stay in touch with them, but they go to Washington DC to serve as a

00:56:34.320 citizen legislator, the citizen, the broad experiences, the trials, the tribulations,

00:56:38.760 the challenges, the understanding, the empathy, and applying all that to help shape the laws of

00:56:45.320 the land. And then after I've done that, go back and live under the laws that I've passed or we've

00:56:50.660 passed. And that's just a philosophy. And I believe that today, not for everybody, but I think the

00:56:56.380 majority of people in the Senate benefits from it. And I think people benefit from it not to get locked

00:57:02.500 up in this very almost encapsulated environment of the Senate or the House of Representatives

00:57:08.860 itself. It was just clear to me. And that perspective came from medicine. The breadth that a clinical

00:57:15.200 person has in taking care of acute medicine and chronic medicine and mental issues in the

00:57:22.440 transplant world, you're taking care of all of that. That the world is much broader and that you've got a

00:57:28.180 job to do. And after it's done, leave, let somebody else maybe brighter, smarter, or bring their citizen

00:57:34.140 legislator experiences there. So it was a philosophy for me and the right one to do. It did allow me in

00:57:41.180 my last term to focus on, instead of fundraising and having to cast votes in a certain way that

00:57:47.460 looked politically good and that sort of thing, which is just part of the business. It allowed me

00:57:52.540 just to have a clean slate, do what I thought was right and move ahead.

00:57:55.520 So would you endorse the idea of term limits? I mean, this idea, if we just said, look,

00:58:00.640 no senator can ever serve more than two terms, no member of Congress can ever serve more than six

00:58:06.120 terms if you wanted to keep it equal at 12 years. I mean, I've heard many people suggest that that

00:58:10.500 could be one piece of the remedy to some of the situations we find ourselves in. I mean, I personally,

00:58:16.520 I find that to be a very appealing idea.

00:58:19.060 And initially, I did too. And you asked about those first days going in. And I think of those

00:58:26.560 first days, just as an aside, my dad, who was a doctor, came up to visit me. And he said on my

00:58:32.200 door, it said, Mr. Bill Frist, another one said the Honorable Bill Frist. And there's in these gold

00:58:38.060 plates on the door and on your chair on the Senate floor. And he walked around, he grabbed him by the

00:58:42.620 arm, he walked back down the hall and said, son, you know, Bill, I love the fact that you're in the United

00:58:49.040 States Senate, I may not have wanted you to be here, but you need to change that, take that tag off and put

00:58:53.460 Dr. Bill Frist there. And so that whole world of being a senator for a period of time, sort of

00:59:02.080 occupying the office, but not owning the office was one. To answer your question, no, I think term limits

00:59:10.000 would be a huge mistake of the United States Senate. This job is complicated. And it's equally complicated

00:59:17.300 to heart surgery and, and, and other things that I've done. The breadth of knowledge to be really

00:59:24.060 good at it. And you can't know everything. But ultimately, every law of the land, every federal

00:59:29.240 law of the land is going to come through you, everyone. And that is really tough. The procedures,

00:59:35.580 we talked about the rule book and the books of precedence and the things that aren't written down.

00:59:40.120 When I came in and then jumping ahead, when I got into leadership, all of a sudden, who did I turn

00:59:46.820 to? I'm not smart enough. I'm sort of, you know, average sort of intelligence overall, and I work

00:59:52.560 really hard. And so I would turn to the person who'd been there for 18 years or 24 years. And I would ask

00:59:59.040 what it was like 20 years ago or 25 years ago. What is the precedent itself? And not go to some staff

01:00:06.100 member who's 25 years old, who's very good, but hadn't been around. And that would not have been

01:00:10.400 possible. That would not have been possible if there weren't a handful or 20 or 30. I don't know

01:00:16.260 what the number is of people that are there. And so the system works pretty good when you have this,

01:00:22.140 this, this, this crucible, this, this mixture of people like me who say, I'm not staying any longer,

01:00:29.360 or Bob Corker, who I helped recruit to the Senate, who said, you know, I'm just going to stay for,

01:00:33.960 for 12 years. So, and then go back and do other things. But I do think this admixture is important

01:00:40.220 because of the complexity of the job. In that first term, what was the camaraderie like between

01:00:45.920 parties? You, you hear stories of, I'm in the middle of a reading a book about Abraham Lincoln

01:00:52.100 right now, and maybe these books somewhat romanticize it, but obviously there have been

01:00:58.060 huge swings in sort of how partisan the country has been. But there are these periods of time

01:01:03.960 in which politicians of opposite parties still socialize together. There was still a degree of

01:01:09.980 respect that existed, even if you disagreed on policy. As you kind of alluded to it earlier,

01:01:15.180 you might spend the week in DC without your family. And that would be a time when these would

01:01:21.360 be your colleagues and you'd go home on the weekend sort of thing. I mean, what was that environment

01:01:25.600 like? And how much time did you spend with members of the opposite party, your own party? And what

01:01:32.800 were those relationships like? And above all else, how did that influence your ability to bring your

01:01:39.180 empathy to the side of, hey, I understand another person's point of view, even if I don't agree with

01:01:43.040 it? Yeah, it's really important. And like you, you don't want to over-romanticize the past. And

01:01:49.660 recent events, you're asking the same question. Is that the way it's always been,

01:01:53.240 or is it's brand new? And the first six years and the last six years were different for me.

01:01:58.260 I served under two presidents, one a Democrat, President Clinton, and the other President Bush,

01:02:03.640 or with them. And it wasn't because of them, but it was because of, in part, media and because of,

01:02:10.600 in part, the internet, in part, initially it was cable TV. As we had more of this sort of real-time,

01:02:17.940 nothing could be done behind closed doors. If I wanted to take a trip called a CODEL,

01:02:24.920 a fact-finding trip to Africa, and I've spent a lot of time in Africa, I would take and go on a trip

01:02:31.700 with four Democrats, senators, and four Republicans, and we would go to four countries in Africa.

01:02:38.300 And we'd be together, we'd travel together, we would share meals together, we would have discussions

01:02:44.380 together. And over the period of sort of that 12 years, but over a period of about four or five

01:02:49.880 years, that became the junket. And so every, you know, New York Times, Wall Street, or anybody

01:02:56.560 would come and say, you're spending taxpayer dollars by having a vacation over in, you know,

01:03:02.300 Southern Sudan.

01:03:03.600 Anybody who's been to Southern Sudan knows that ain't a vacation.

01:03:06.960 Yeah, no, exactly. But, you know, it's easy when you're in this sort of fully exposed media world

01:03:13.280 in real time, where it's hard to counter everything. And so that really contributed a lot. So early on,

01:03:20.960 probably the first four years, a lot more of that having dinners, and these aren't like Georgetown

01:03:27.320 parties and all, we're talking about in the Senate dining room, sitting together. And then over that

01:03:32.940 12-year period, much, much less of that. And it's gotten much, much worse since then. I'm still

01:03:38.700 very close to a number of senators, and it's gotten much, much worse since then. But the trend began

01:03:44.220 to change right through that period of time.

01:03:47.060 And really, the scrutiny of the media played a role in that. Of course, the critic will argue, well,

01:03:54.120 isn't that the job of the media, to bring the critical eye to it? I mean, what is that balance

01:03:58.900 between the media holding politicians accountable versus actually creating a counterproductive

01:04:05.280 environment where it polarizes everybody more and creates distance between them? How do we think

01:04:10.660 about this?

01:04:11.180 Well, we're seeing it play out. And I think you're exactly right. The transparency is critically

01:04:15.260 important. And past politics has played that out in our history, that hiding things in the long run is

01:04:23.020 unhealthy and destructive to our government, to the fundamentals of our democracy. I think what

01:04:29.140 changed it all is that what we're seeing today more than even when I was there, but is the

01:04:35.760 misinformation that campaigns. If the media, like on this whole thing of CODELs being junkets,

01:04:42.480 make the accusation, there's no way really to counter it. And if misinformation is put out there,

01:04:48.060 and it's in real time. And again, this is the period of time, you know, before Twitter and before

01:04:52.680 Facebook and all. But if you put the information out there, it was much harder to counter. But it

01:04:57.440 was the same sort of stuff. It was misinformation that was there. Therefore, the institutional

01:05:01.160 structure, the corporate structure of having one lunch together, which we used to do, Democrat and

01:05:07.160 Republican, ultimately evolved into the Republicans going to one room and Democrats going to another

01:05:12.020 room. Something they already did for business, but that joint room of getting together

01:05:16.240 disappeared. And that's unhealthy. And there are ways that you can fix that. I won't jump ahead

01:05:22.360 with that, but there are ways that you can fix that. And it does have to be fixed. And it comes

01:05:26.880 back to this being a doctor, I think. The empathy word really does come back to this connectedness.

01:05:35.640 Doesn't mean you have to agree, but this connected of seeing two sides of things. And there's just less

01:05:39.740 empathy in the corporate structure of the United States Senate today.

01:05:43.740 What committees did you sit on in your first term in the Senate?

01:05:46.240 Yeah, it's interesting. I sat on the banking committee. Actually, I had been on the board

01:05:52.340 of a bank, ironically, before. It's not the reason I went on it, but Pete Domenici was on

01:05:56.880 it. And when I was choosing my committees, the way committees are chosen, I was 100th in

01:06:02.160 seniority. So I had 99 people above me.

01:06:05.380 Were you the only freshman senator elected in 94?

01:06:08.340 No, there were others elected. But the ones, if you've served in public office before,

01:06:13.320 you get credit for it. If you've been a governor, you get credit for it.

01:06:16.780 Yeah, yeah, yeah. So you are the lowest totem pole.

01:06:19.320 Yeah. I mean, I thought I was okay being a heart surgeon and taking care of people and

01:06:22.920 saving their lives. When I got up there, boy, they could care less, especially when it came

01:06:26.540 to committee choice or it came to anything that had to do with appropriations or power or that

01:06:31.160 sort of thing. But the committees I ended on were great committees. One was the banking committee.

01:06:35.200 Fascinating time and always a good committee. Has no power per se, but a really important committee

01:06:42.120 in terms of constituents back at home. And the HELP committee, the Health, Education, Labor,

01:06:46.800 Pension Committee, which is HELP. And that did include things like I chaired the subcommittee

01:06:52.040 on disability policy. And for the whole United States of America, every law of the disability

01:06:58.980 world had to come through that particular committee. And then went to foreign affairs about two years

01:07:05.820 later and stayed on that throughout because I had done so much travel to other countries

01:07:11.720 doing medical work and it fit there. But those were the ones in the first few years that I was

01:07:17.580 on and learned a tremendous amount. And then in the last four to a year, six, joined the Commerce

01:07:23.020 Committee. And the Commerce Committee, that was the time there was telecommunication and all

01:07:28.160 of the great reform that was going on then. I've resisted asking you this question before

01:07:32.740 because I wanted to ask you for the first time during this discussion. How is it that someone

01:07:38.700 so young and so junior in tenure can become the Senate majority leader at such an early time in

01:07:46.460 their tenure? So I guess walk me through the late 90s. You're obviously going for re-election.

01:07:52.200 You won by quite a healthy margin. But what were the string of events that allowed you to go from

01:07:59.180 being still a relatively junior senator to being, you could argue, the second most powerful person

01:08:05.880 in Washington after the president? Yeah, it's an interesting sort of line narrative in large part

01:08:13.420 because that was not my goal. And if you're going to start with 100th in CRT and jump to number one in a

01:08:20.100 period of six years, it just sounds crazy. And it is crazy. And Lyndon Johnson did it, but he'd spent

01:08:28.460 all those years over in the House of Representatives. But to come in...

01:08:32.360 By the way, LBJ was, I mean, generally considered one of the most effective Senate majority leaders.

01:08:38.680 I mean, some people still wonder how he actually managed to take the vice presidency as such a step

01:08:44.800 down. And of course, how history would have been different had he not. But yeah.

01:08:48.260 Yeah. But the sort of sequence of events was I won re-election. At the time, there were Bob Dole,

01:08:55.180 who is just an iconic leader as well, and Trent Lott and others were sort of the Trent Lott

01:09:02.240 representative, a younger generation, but all very senior to me, were sort of added to each other

01:09:08.480 and competitive and sort of the intra-family politics and class office sort of stuff. And I

01:09:14.960 didn't pay any attention to that, really. What I was interested in, and I use this in different ways

01:09:20.540 today, now that I'm out of politics, and if I'm on a board, I like to go to the nomination committee,

01:09:26.280 that the future of a body, of an institution, if you really say how I want to affect a board,

01:09:33.440 a nonprofit board, or a for-profit board, or the United States Senate, 100 people,

01:09:37.620 the best thing to do is to get involved in the determination of who's in the room and who is

01:09:43.100 not. And therefore, in leadership, the sort of fourth or fifth position down, depending on how

01:09:50.780 you look at it, in the Republicans, there are about 50 Republicans there, is a more political

01:09:57.260 position called the National Republican Senatorial Committee. But they're in charge of the 33 elections,

01:10:02.320 that one person is, and they get selected by the body to choose the next generation of senators.

01:10:08.740 Not choose them, but you recruit them. And, you know, I recruited Lamar Alexander, I recruited Elizabeth

01:10:14.340 Dole, I recruited John Thune. Maybe they would have ended up there, but maybe probably for most of them,

01:10:20.380 they would not. And so I ran for a leadership office then, and that leadership, again, I did this

01:10:26.640 one, I came there to do policy, to pass big stuff that would help people in health and welfare,

01:10:31.960 and lift them up in education. So I said, let's do that position for two years, and then I could

01:10:37.120 come back and do policy the last four. And so that year, six years in, between sixth and eighth year,

01:10:43.680 we did what you implied or you suggested earlier. I ran that group. I represented the United States

01:10:50.560 Senate in every state. I had to raise money for the Senatorial Committee. But we won that year 11

01:10:56.820 seats, 11 Republican seats. It was the first midterm of George W. Bush. As you said earlier,

01:11:06.060 there's a huge bias for the Democrats to win.

01:11:09.240 Right, but 9-11 shifted it, I'm sure, right?

01:11:11.720 You know, it was all sorts of macro everything coming in. But we won, and we won big. And so I worked

01:11:21.660 it hard. And again, being a heart surgeon, you're not trained to do that sort of thing. But I traveled

01:11:27.000 and I recruited people. And I'd go to New York, I'd go to North Carolina, I'd go to Nebraska. I'd sit

01:11:34.000 down with 10 people who wanted to run for the United States Senate. I'd spend hours with them.

01:11:37.660 I'd talk to their families and their spouses and say, yes, and say, this isn't going to work out for

01:11:42.500 you. And then I have to raise money as well, state to state, and say, this is important to support

01:11:47.360 these campaigns. And both parties have this. Is the expectation at that point that if you broke

01:11:52.740 even, that would be a victory to not give up seats in your first midterm? No, no, no. You were in it

01:11:57.920 to win it. Yeah, no. Well, no, the expectation was it's very unlikely to even break even. In the first

01:12:04.380 midterm of any party of the president, just, you know, just historically, 9 out of 10 times, loses

01:12:11.440 seats. So I wanted to keep the losses to a minimum. I wish I could say it was to break even. But we

01:12:17.140 won and we picked up seats. And with that, I developed a certain credibility among my people.

01:12:22.560 People weren't jealous of me either because I'm just a doctor doing his best. You know,

01:12:29.080 good guy can bring people together, can bring the Democrat, can bring the Republican together. But,

01:12:34.620 you know, and by historical precedent, not, you know, nothing great in the family started breaking

01:12:40.740 down. And without going into details, there was a lot of dissension in the party. And it was most

01:12:47.080 it was behind closed doors in these caucuses. And when it came to elect the majority leader,

01:12:53.540 again, I didn't want to be a majority leader. It wasn't my goal. In fact, if you go to be in

01:12:57.720 leadership, it's hard to do big policy. It's hard to do the sort of things I ended up doing,

01:13:04.820 HIV, AIDS, PEPFAR, these huge things that affect millions of people if you're the leader.

01:13:10.440 And you look at what McConnell, if you're, whoever's the leadership, Schumer and McConnell today,

01:13:14.500 and whoever it will be, you know, as people listen to this in the future, they don't have time to do

01:13:19.220 the legislation or the policy. They're out there managing these, hurting these cats being the

01:13:24.020 leader. So I didn't want to do that. I only had 12, I only had four years to go. I didn't want to

01:13:28.360 spend four years hurting cats. But when it came down to the election, there were five people who

01:13:34.060 wanted to be majority leader. And all of them, to be majority leader, you had to have majority vote.

01:13:39.540 And one might have 12 votes, and one might have nine, and one might have eight, and one had four

01:13:44.440 and six. And then you'd get together with other people. And I wasn't a part of any of that. But

01:13:49.120 then it got down to where nobody had the votes. And people came to me, and I had a group of people

01:13:55.860 because I'd come off these Senate races with credentials. They said, well, what about you?

01:14:01.080 And then all of a sudden, all these, all four of the other people came to me and said,

01:14:04.640 if you will do it, they said, I can't win. And if you are interested, we want you to be a majority

01:14:10.020 leader. So I haven't really told that story publicly. But I think it is important for people

01:14:15.480 to, it humanizes the place. You know, this is no different than elections in life, and things are

01:14:20.620 fair, and things are unfair, and luck is a part of it. But that's it. That's the story. Did not have

01:14:25.960 the credentials, didn't want it, did want the two-year job, so I could go back to policy. But the two-year

01:14:32.080 job did well, but got lucky, really lucky, and won. And then at the end of the day, because,

01:14:38.680 in part, because of this doctor thing. They also saw me as somebody that is non-threatening.

01:14:43.140 They said, if this guy comes in, I want to stay here forever, they would say to themselves.

01:14:48.620 This is my job. This is my pinnacle in life. And my pinnacle in life is doing heart transplants,

01:14:53.140 you know, out the window going to Vanderbilt and saving lives every day by just doing my job.

01:14:59.440 And, but this was the pinnacle in life to a lot of people. And so they probably said,

01:15:04.360 well, you know, if I give him my people, and I work with him for four years, when I leave,

01:15:09.860 I might be the one that he says should be the next majority leader.

01:15:13.500 As you alluded to earlier, these next four years, while you're a Senate majority leader,

01:15:17.380 are quite busy, and potentially one of the signature things you're a part of is PEPFAR,

01:15:21.900 which you've alluded to. Now, I've always found it interesting how little Americans understand

01:15:29.020 PEPFAR. And yet, you know, when you talk to people in Africa, it's a very different picture

01:15:34.240 you get there, right? I mean, I think when you go to the parts of Africa that have been

01:15:37.540 impacted by it, they hold the administration in such high regard. And yet, for some reason,

01:15:44.820 it doesn't get, I think, the attention it deserved domestically. Do you agree with my assessment?

01:15:50.260 And if so, why do you think that might be the case?

01:15:53.620 I partially agree. You know, PEPFAR...

01:15:56.060 Let's start with telling people what it is. Yeah, yeah, yeah.

01:15:58.300 We're talking about HIV AIDS. And it makes sense, being the only doctor in the Senate,

01:16:03.620 that people would come to me early on. And I had spent years going to Africa,

01:16:09.780 spending two to three weeks a year taking care of people, doing surgery, training people,

01:16:15.080 worked with a group called Samaritan's Purse initially, and then other groups on my own.

01:16:19.100 And throughout Africa, mainly in South Sudan, and a province called the Louis province there,

01:16:25.160 but also in Ethiopia and South Africa and Botswana. And I would see people dying there a lot. And there

01:16:32.500 was no testing for HIV AIDS at the time. And then I came to the United States Senate and worked with

01:16:38.320 President Clinton. And President Clinton said, yeah, it's a big issue. And we'd put maybe a couple

01:16:42.860 hundred million dollars into it, but never did anything about it.

01:16:45.720 And then this right wing, not really right wing, this middle but right wing George Bush came.

01:16:52.060 And President Bush, this is 2000, had never been to Africa. Maybe he'd been one time when his dad

01:16:58.300 was president for a night. In conversations with him and other people, Tony Fauci, who everybody's

01:17:04.620 heard a lot about today, was a huge part of it. I bring pictures back of people dying of HIV AIDS.

01:17:09.440 But the story at that time was that three million people, three million were dying every single

01:17:16.540 year because of a little virus that in 1980, in 1981, we didn't even know what it was. We had

01:17:23.580 never seen it in the United States. But with three million people dying of that and a couple of

01:17:29.420 million dying of tuberculosis and one of malaria, this was by far the biggest killer globally of a

01:17:34.700 disease. And so President Bush basically listened to the stories, focused on it, sent Tony Fauci down

01:17:41.360 to Africa. You know, is this something we could do something about? He came back in a surprise way

01:17:46.280 at the State of the Union missions, 2003, when I was majority leader. I knew it and probably five or

01:17:52.160 six other people knew it. Basically said, I'm going to make the single largest commitment to a single

01:17:56.040 disease that's ever been made by a president of the United States. This little cagey virus,

01:18:01.700 HIV AIDS. At the time, Republicans and faith based people, you know, thought it was a disease of

01:18:09.660 gays and was bad. And the Jesse Helms of the world basically said it was, you know, a call from God

01:18:15.020 and punishment and all. The left wasn't doing anything about it, but they talk about it. But

01:18:20.700 nobody would step up. So President Bush, I wrote the Senate bill and I, but a lot of others got together

01:18:28.280 and passed this legislation about six months later in record time. Jumping ahead, 20 million people

01:18:33.660 are alive today because of that five page bill that surprised everybody coming out of this president.

01:18:39.440 And it's no small figure. I mean, we're talking, you said, you know, Clinton put a hundred million

01:18:42.800 into this. I mean, your bill put $60 billion into this, if I'm not mistaken. Is that right?

01:18:48.880 Over time, we were spending about 200 million a year. And again, President Clinton was right on all

01:18:53.280 the issues. And later, after he left office, as you know, made a big issue about it and still has

01:18:58.080 done unbelievable things through the Clinton Foundation for it. But at the time, there were

01:19:02.720 just so many other things going on. So it's been about 200 million. And then that first year with

01:19:06.900 President Bush that we got it through the first year, $3 billion and then $3 billion a year for

01:19:13.020 five years. And then over time is the $65 billion because subsequent presidents have continued

01:19:19.280 with that program coming forward. But the interesting thing is it came from way out to

01:19:23.720 the right. And it came from a people who brought the left and the right together in a bipartisan way.

01:19:30.720 And when I brought it to the floor of the Senate, you know, it was close, but it was bipartisan and

01:19:36.500 it passed. And when the House passed it. So it will be legacy and legacy changing. And then the

01:19:42.700 spinoffs from it, or that money is spent, it's not just on HIV agents, on tuberculosis, malaria,

01:19:47.440 infrastructure, surveillance, putting clinics and cities and communities and villages and towns

01:19:53.940 all over the world, not just Africa, but Russia, China, and around the world.

01:19:58.520 Now, one of the things that put you at a little bit of odds with the party was when you broke with

01:20:03.060 the party's views on stem cell research. Initially, your view was in line with the Republican Party,

01:20:10.100 which was to be against stem cell research. You changed that view and in the process,

01:20:15.200 presumably upset people in the party. So I guess I'd start with what changed your mind?

01:20:20.120 Yeah, you know, it's interesting to sort of go through what stem cell research is because

01:20:24.820 the changing of the minds or the switching of positions or sort of the role of a senator is

01:20:30.860 one that's kind of worth going through. So I had come to the Senate as a physician. I know brain death

01:20:36.680 well because all my donor patients, I'm involved in all of those. I am in immunology. When I came to

01:20:42.740 the Senate, I was in and, you know, did things like disability policy and health. So people came

01:20:48.200 to me on this particular issue coming in. And there was an amendment back in 1996, which basically

01:20:54.380 banned federal funding of embryonic stem cell research, not adult stem cells. Embryonic stem

01:21:01.500 cells being the ones that were just discovered in 1998. So this is fairly new at the time. And the

01:21:07.840 beauty about those embryonic stem cells, they do something that no other cell had ever done.

01:21:12.140 And that is you could take it and it could become a liver or a heart or a, you know, pancreas.

01:21:16.960 You could kind of channel it in those directions. And the second thing, it was like a, back in those

01:21:21.480 days, we'd say it's like a copying machine. You can make unlimited copies of it. No other cell ever

01:21:25.940 in the history of man had we discovered. So then you had people who said these cells are powerful.

01:21:31.960 Going back to the heart transplant, why not take a few of those stem cells, stick it in the heart,

01:21:35.600 make that heart come alive. The problems had never been done before. And ethically,

01:21:40.640 people didn't know whether it can be done or should be done. But if you had Parkinson's disease,

01:21:44.900 neurodegenerative disease, the hope for everybody, including me as a scientist who kind of lived in

01:21:50.640 this world, was tremendous. So the question was, how do you take these embryonic stem cells

01:21:55.420 and in an ethical construct, allow that research to go forward? And that was always the issue.

01:22:02.420 And do you do it with federal monies or you do it with state monies or local monies? So

01:22:07.460 the issue is all what happens at the federal level. See that amendment. And then President Bush came out

01:22:11.720 in 2001 and he said, we're going to fund embryonic stem cells for the first time, but we're only going

01:22:17.660 to do very little. We're going to limit it because we don't know if these cells are good or bad.

01:22:22.460 That's sort of one line. The more important line at the time was, is it ethical? The embryonic stem

01:22:29.540 cells, the only way you could get them is by creating an embryo and then destroying the embryo.

01:22:35.720 So you can see real quickly where this is going. You got pro-life, pro-choice, 50-50 in America.

01:22:40.920 Pro-life people said that the embryo has the full genetic code. It is all you got to do is nourish it.

01:22:46.580 It is a human. It may be early on, but it's in the first stage of development. So the ethical

01:22:52.640 issues there were Americans believe that, or half of America believes it has sort of moral value of

01:23:00.020 some sort. Do you allow embryo mills to be created? And so that's where the ethical issue, a fascinating

01:23:06.160 issue. So Bush said, no, we can't do that. Let's restrict the number of cells. And he said,

01:23:11.920 here's 78 cell lines because they've already been created, but let's not destroy any more embryos or

01:23:17.640 create and destroy embryos. And so he limited 78 lines. So I endorsed that. And about two months

01:23:25.160 before that, and this was all written up in the Wall Street Journal because it was all new science

01:23:29.660 and political. I'd written, gone to the floor of the Senate and said, I think that here are my 10

01:23:37.060 principles. Let's put them forward and engage federal funding. State funding is okay. And local

01:23:44.060 funding is okay. That's outside. But for federal funding, let's limit it like Bush limited. He

01:23:50.180 limited to 78 cell lines. I said, instead of doing that, let's sort of stay with the times and use

01:23:58.220 these blastocysts or these little embryos that are used in fertility clinics that are otherwise going to

01:24:03.460 be thrown away. But they're still, they're still pluripotent. These are still completely

01:24:08.200 pluripotent stem cells. Exactly. You create five of them, you implant a couple, the other three are

01:24:13.880 thrown away, discarded. So my argument in my 10 principles that I went to the floor in 2000

01:24:19.720 was that use those. So Bush came out with something different. He limited to 78 cell lines.

01:24:26.940 So I endorsed that because at least we were getting federal funding of stem cells. And then we jump four

01:24:31.780 years later. And this is what's really interesting to me. And this is really important, I think,

01:24:36.080 for our senators today. Science changes over time. You learn things. There are better techniques. There's

01:24:41.400 evolution of knowledge. You clinical trials prove things. And it got to be four years later

01:24:47.380 that it was clear those 78 cell lines didn't work. They were contaminated by mouse cells. Only about 22 of

01:24:54.800 them ended up being good. And therefore, what was intended to be sort of a limited opening of the door

01:24:59.820 for federal funding, in my mind, had failed because science had demonstrated those cell lines

01:25:05.660 were not sufficient. So I pulled my 10 principles back out, again, went back to the floor of the Senate,

01:25:11.660 put those 10 principles out there. And the reason it became such a big politicized issue is that

01:25:17.140 President Bush did not agree with me and the majority of the Senate and the majority of the House.

01:25:23.040 We passed in 2005 a bill called, I think it was the Stem Cell Research Enhancement Act. It passed. It

01:25:30.400 says you could use these blastocysts. An ethical construct was set up. You got consent set up.

01:25:37.040 And then that bill passed overwhelmingly bipartisan, but it was vetoed by President Bush. And so then

01:25:44.840 people said that Frist and Bush are in totally different areas. But from the day one,

01:25:50.620 the embryonic stem cells, to me, being a heart transplant surgery, were the most exciting science

01:25:55.480 that had come by in 10 years. But when this whole ethical issue came up, out of both my own

01:26:01.680 beliefs, you know, when you have nascent life in an embryo, and you had these embryo mills being

01:26:09.180 created, women were being paid $400 to create embryos to have them destroyed. And there was no mechanism,

01:26:15.300 discipline mechanism around that, that we had to create that. And ultimately, it got created.

01:26:19.880 And now we jump, you know, 10, 15 years later, the same principles that I had put in in 2000 and

01:26:26.400 2005 are the ones out there. And that's where that research has gone. And in retrospect, it's

01:26:31.900 probably been pretty good in the sense that the stem cells eventually are going to live up to the

01:26:37.840 promise. But we're 17 years later, and adult stem cells are used in bone marrow, and cord blood is

01:26:45.160 being used. That has no ethical issues around it. It's these embryonic stem cells. And with the

01:26:50.480 research that's out there, it's, you know, 17 years later, and some good things are happening. But

01:26:55.000 still, there's no embryonic stem cells being used to treat the Alzheimer's and Parkinson's.

01:27:02.220 Yeah, I mean, it's such a hard problem, right? The challenge is, how do you instruct the stem cell?

01:27:08.240 Where is the instruction set that says, I want you to go and replicate 32 times, 32 doublings,

01:27:15.080 and become cardiac myocytes? And this subset of you are going to go on to develop Purkinje fibers,

01:27:21.340 and this set of you will not. I mean, it's, it's, we're still so far from cracking the code of what

01:27:27.940 the instruction set looks like to the stem cell. So it's, this is step one of 10, basically, in terms

01:27:35.460 of that. But it's hard to tell people that. And as a policymaker, you have to make the decision,

01:27:40.880 you have to set up the construct, or you're not going to fund funding. But you literally have

01:27:46.000 thousands of people who are dying, and they have the chronic diseases. And then they have a group of

01:27:51.720 people telling them that within two years, this was all in early 2000s, within two years, your

01:27:57.060 Parkinson's could be, or your, your neurological injury, severing of the spinal cord can be cured with

01:28:02.920 these cells. And therefore, we need to open up the field and forget destruction of embryos or all

01:28:08.480 these moral concepts of life. And that's the tough job of a policymaker, you got, you know, 100 regular

01:28:14.700 people there, who, you know, some are smart, some are not, that are, you know, maybe not perfectly

01:28:21.500 representative of people, but they've got to make these decisions. So, you know, it's the sort of thing

01:28:26.880 that, you know, at the end of the day, we increase federal funding for stem cells, constructs were put

01:28:31.260 around it, imperfect, his approach was different than mine. People, you know, made a big deal about it at the

01:28:37.720 time. But, you know, at the end of the day, I think it ended up working out with pretty, pretty well, and

01:28:43.900 learned a lot. And it comes back to science a lot. And these fields that are just so promising, I mentioned

01:28:51.200 synthetic biology, and we think of CRISPR technology today, and the creation of kids with blue eyes and brains that are

01:28:58.700 good in math and all, all of which we could do. But how do you slow that down? How do you bring

01:29:03.800 the discussions, not just to the Capitol, and not just to the academic centers, but to Main Street,

01:29:11.280 and get the right ethical constructs? And that's what our policy, I'm not a policymaker now, in that sense.

01:29:16.760 But that's what these people in Washington do. That's what we hire them to do. And that's what we

01:29:22.440 need to hold them accountable. And they need to do it the best way they can at a point in time.

01:29:26.360 So things are going to shift with time. In that particular one, luckily, I did the same 10

01:29:31.520 principles in 2000 as I did in 2005 when I passed the bill. It got vetoed, by the way, so I lost.

01:29:37.180 But ultimately, back under President Obama, the same bill was taken out and passed.

01:29:42.020 What are the restrictions on a president's ability to veto? Can a president veto any amount of majority,

01:29:47.700 any Senate majority? If 99 senators are in favor of a bill, the president can still veto it?

01:29:52.800 Well, yeah, it's a good point, because if you could have a majority that votes for it,

01:29:57.520 or a super majority, but you have to have two-thirds or three-poors come back. So if you vetoes,

01:30:02.280 you have to take a whole other vote and then override that veto. So he or she has that intervening

01:30:07.020 time to put pressure on people and change that.

01:30:11.680 Another very complex issue that you weighed in on, which ties into your past,

01:30:18.140 which is this idea of end of life, right? I mean, it's funny. I remember a really complicated

01:30:23.300 case when I was in medical school at Stanford, which involved a patient who was more or less

01:30:30.660 brain dead, but there was a very complicated family dynamic. And I don't remember the exact details,

01:30:36.820 but it was one of those scenarios where every ethicist in the hospital had been in that room

01:30:43.060 to try to talk to that family and resolve the withdrawal of support. And interestingly,

01:30:49.640 even though this case had nothing to do with cardiac surgery, ultimately the person that came

01:30:55.580 in and mediated it was Bruce Reitz. And it's an interesting story because again, here's Bruce

01:31:02.380 Reitz. At the time, he was the chair of cardiac surgery at Stanford. He had by now come back from

01:31:06.680 Hopkins. And you know him, so this probably isn't surprising to you, but you don't think of like

01:31:11.500 the chair of cardiac surgery being the warm fuzzy, but he was like the most soft-spoken human alive.

01:31:17.720 Like you would never see him and think that that's the guy who did the first heart lung transplant

01:31:22.160 or anything like that. But it was sort of like, I don't know, he spent two hours with this family

01:31:27.780 and everybody had come to a point of comfort that in the case of that patient support should be

01:31:32.420 withdrawn. So of course, as a transplant surgeon, you are intimately familiar with what the criteria

01:31:39.360 are for brain death, what makes a donor, what does not make a donor, et cetera. And so again,

01:31:45.240 here you are now Senate majority leader and a very public case comes up, this case of this young woman,

01:31:51.920 Terri Schiavo. And I guess just for folks who don't remember this, and you can correct me on

01:31:55.720 some of the details, but my recollection, because I was in residency, this was such a big discussion

01:32:00.580 for us. This is a young, healthy woman who I guess unbeknownst to a lot of people had an eating

01:32:05.520 disorder. So she had bulimia and through lots of repetitive purging had developed profound

01:32:12.520 hypokalemia. So very low potassium. So she's otherwise looks perfectly healthy on the outside,

01:32:18.460 but I believe her potassium got as low as two to 2.5 milliequivalents, which not surprisingly put her

01:32:24.860 into an immediate cardiac arrhythmia and arrest. By the time the paramedics arrive and resuscitate her

01:32:31.340 because she's so young and healthy, they can get her heart beating again, but her brain has been

01:32:35.660 without oxygen for minutes. No one really knows. This was in 1990, if my memory serves me correctly.

01:32:44.700 Fast forward a few years, now her husband, Michael, and her parents, whose names I don't remember,

01:32:51.740 are basically having a different point of view about what to do. And the husband believes

01:32:56.080 she's going to be in a persistent vegetative state for the rest of her life. This is not what

01:33:00.740 her wishes were. She's being fed through a tube. The parents feel otherwise. And it just keeps

01:33:07.140 escalating its way through courts and it gets higher and higher and higher and higher. I don't

01:33:11.500 remember exactly how it got to the point where Congress was now being asked to weigh in, but maybe

01:33:15.720 you can pick up the story of how this basically rose to a national story. And frankly, even potentially

01:33:21.460 involved the U.S. Congress. Yeah, it is a fascinating story. And this is one, again,

01:33:26.400 and Peter, I haven't talked about a lot in part because it is complicated and you do need the sort

01:33:33.800 of the time and we can do it very quickly, but... Oh, no, no. We don't have to do it quickly. Yeah,

01:33:37.620 yeah, yeah, no. But no, it is a fascinating case and because it has implications for everybody listening

01:33:42.600 to us today. Everybody. And it will be, have even greater implications in the future as technology

01:33:50.220 can do these miraculous things. Here it was miraculous in the sense that she could even be

01:33:56.140 kept alive on a ventilator for a long period of time. But increasingly, it's going to get more

01:34:02.100 complex because technology and science is going to give us these tools to use. So lots of lessons

01:34:06.820 and so it is worth going through it. So you're exactly right. 1990, Terry Schiavo collapsed,

01:34:11.720 hypokalemia for just a persistent vegetative state is a medical term. It's an important term here

01:34:19.660 because the law uses it. But for people who are listening to us, you know, you're on a ventilator

01:34:25.020 and you can move and open your eyes, but it's just, you have to be supported overall with both feeding

01:34:31.400 tube as well as a ventilator. And Michael, her husband, you know, did everything, at least in

01:34:37.140 my review at the time. He took her to UCLA, took her to multiple centers and for rehabilitation.

01:34:43.100 And then three years later in 1993, he'd given up basically. And I don't know, I wouldn't involve

01:34:48.160 the family then. This is 10 years later that I got involved. But the issue was exactly as you

01:34:54.900 described that all of Terry's blood relatives, the mother, the father, the brother, the sister,

01:35:04.740 objected to Michael putting her on a DNR or removing the tube. I do not resuscitate or remove the tube.

01:35:12.580 So you had this dichotomy of walking the room, just like you said, Bruce did. You had on one side,

01:35:18.020 one person who by the law says if she's in a persistent vegetative state, the husband can make

01:35:24.720 the decision. On the other side of the room, you had all the mother and father who raised her,

01:35:30.720 who cared for her, her brother, her sister, who said, no, she's responding to us. She's alive.

01:35:37.340 Touch her, feel her, look in her eyes. She recognizes us. And so the parents and Michael disagreed on

01:35:44.400 their impression. They also disagreed because she had, and this is what the implication is,

01:35:49.900 everybody listened to sort of this part. She had nothing written down. She had no living

01:35:54.720 will, no advanced directive. And therefore you had the parents and everybody says, well, of course,

01:36:00.880 she's a devout Catholic. She values life. And you had the four of them saying, you know,

01:36:07.620 we'll support her. We'll take care of it. Financially, we'll take care of it. And then

01:36:11.020 you had Michael who by the law would have that responsibility of saying DNR or not.

01:36:17.260 I just want to interject there for a second. I think it's such an important point you made,

01:36:20.940 and I had actually scribbled notes down to bring it up. So I'm glad you did. I don't think you and I

01:36:26.620 as doctors could overstate the importance of an advanced directive enough. And I think a lot of

01:36:34.260 these issues could be resolved if, well, you don't have to worry about it. You go through this exercise.

01:36:40.440 I mean, my wife and I did this 12 years ago, sat there in a lawyer's office and spent an hour

01:36:47.120 going through what we wanted and what we didn't want down to the levels of detail that is comical,

01:36:53.160 right? Now, not everybody has the luxury that might not have the medical. My wife's a nurse. So,

01:36:57.120 you know, we could talk about it through, well, this is, I would tolerate this many line changes

01:37:00.920 at this many weeks of a trach and this feeding tube, blah, blah, blah, blah, blah, blah. But

01:37:04.040 it is very important, I think, to do this. And hospitals are getting better at it now for people

01:37:09.800 admitted electively to at least have a box that you check that says, do you have an advanced

01:37:14.320 directive? But I think everybody should have one of these things because the time to build the roof

01:37:20.720 is when the sun is shining. And the time to have this discussion is when clear heads prevail.

01:37:26.740 And it's hard. You just have to do it. People don't like to think about death or where they're

01:37:32.140 going to be buried or wills. This is one that out of respect for your loved ones. And it plays out

01:37:38.780 here. And I'll mention it again because I'll come back to it because it had real implications. But

01:37:44.080 they had nothing. The interpretation of one set of relatives and then the husband were very different.

01:37:49.240 So, jump ahead to seven years. Her feeding tube was taken out. Then a court, these courts, as you

01:37:54.280 said, kind of came in and they replaced it. At the time then, 33 medical specialties, and this is why I

01:38:00.100 had to go back and review all this eventually, came forward and had affidavits that her condition

01:38:05.520 was not beyond some sense of recovery that she could improve. And so, seeing that, you know,

01:38:12.140 complicates things a little bit because she's in this either minimally conscious state or persistent

01:38:18.320 vegetative state. So, in 2003, the court ordered five doctors, these are state courts, ordered five

01:38:23.960 doctors to test Terry. Two appointed by Michael, the husband, and two appointed by the family. And then

01:38:31.260 one appointed by the judge. Three to two, they said she was in a persistent vegetative state and it

01:38:36.780 would be okay to withdraw therapy, take the tube out, take her off the ventilator. The two who voted

01:38:42.380 against that said, no, she's in a minimally conscious state and you can recover. So, she stayed alive for

01:38:48.860 about six days. And during this six days, it became this huge global issue. It went to the state of

01:38:55.440 Florida. The state, their equivalent of their House and Senate, the legislators got together

01:39:00.620 and actually passed a law in that six-day period that gave Governor, Governor Bush at that time,

01:39:07.880 the order to put the feeding tube back in. All this was over a six-day period. The Supreme Court there

01:39:14.220 struck that down. And again, this is kind of the politics. And you say, oh, gosh, as you said,

01:39:19.760 the Bruce rights of the world, these sorts of decisions as a physician, and I'm talking about one

01:39:25.120 who's run disability policy for America, who's been in brain death, who's been in the whole field

01:39:29.620 of transplant, whose whole career has been around life or death, these decisions should best be made

01:39:34.980 by a family with a directive, with a physician or a caregiver, maybe with a faith person in that room.

01:39:43.480 But this got elevated throughout the politics. You had Pope John Paul made a statement on behalf of

01:39:49.980 the family and the sanctity of life and that they would support her and that was their belief.

01:39:55.120 The brother, the sister, the parents said, keep her alive and that they would support it

01:39:58.440 financially. And somebody gave $2 million or said they would give $2 million to support her.

01:40:03.820 So that's it. So of course, coming back, being the only doctor in the Senate, and maybe it was

01:40:07.460 one more at the time, and knowing brain death, I was involved in all those discussions. And when I was

01:40:12.240 at Stanford, the ethical issues, the disability policy, the only physician. So I jumped, didn't want

01:40:18.700 to do it because I don't think it should be done. It should be really rare, really exceptional.

01:40:22.160 But this had become a global issue on the news every night. And again, it was a long time ago

01:40:28.340 at this point, 2003. So I asked myself at that point, does the government have the right to

01:40:33.680 terminate life when the family objects to it, if they'll financially take it? And that was kind

01:40:39.700 of where I came down to. And the question is, which part of the family do you listen to? The one

01:40:44.860 that the law would give it to, ultimately, it would be the husband or all of the siblings and

01:40:51.940 the loved ones and the people who lived with her and taken care of her in large, large part. And

01:40:57.300 it's a little bit like coming back to the transplant world. If I walked into a room to remove a donor

01:41:02.620 heart, to bring it back to Vanderbilt to transplant it, and I walked in the room and the patient was

01:41:07.240 there, the operating room, and there was a spouse who said, no, she said, take the heart. It's okay.

01:41:12.980 But if the rest of the family said, no, we don't want you to desecrate the body of our loved ones

01:41:19.280 and take the heart, even though the law would say I could do it, you know, under these donor laws that

01:41:23.760 we have, I wouldn't do it. Of course, I wouldn't do it. I wouldn't. To me, it's just not the right

01:41:29.060 thing to do. So what did I do? Have you ever been in a situation like that, by the way, where

01:41:32.820 the legal spouse, the person with the legal right to authorize the transplant says yes, and a group

01:41:41.080 of others say no? It's fairly, as you can imagine, it's fairly, it's rare, but it's common. And so,

01:41:47.420 no, I did not. I would not take off in the airplane tonight if I knew, talking to the donor

01:41:52.780 counselors up there, that the family disagreed. Although legally, it says, so I avoided it totally.

01:41:59.780 And others may have done it, but I would not do it. But yes, it's not that, you know, as you can

01:42:04.480 imagine, you get six members of a family and they all disagree about something unless you have a

01:42:09.040 Bruce Wright's walkout. And you've, you've described that well. So the first thing I'll go

01:42:12.300 faster. The first thing I did is I called the last neurologist to examine her. And he said,

01:42:16.360 she's not in a persistent vegetative state. It's a mentally conscious state.

01:42:19.820 What is the difference there? I mean, I want to just kind of make sure some people understand

01:42:22.760 what we're talking about. She has some brainstem function. For example, if you touched her cornea,

01:42:27.920 she'd blink. Presumably, if you injected ice water in her ears, you'd get a doll's eye reflex.

01:42:33.180 Did she have a gag reflex?

01:42:34.200 She had a minimal gag reflex, which, you know, so she had, the definition is not by a single test.

01:42:41.360 So it is a clinical test. And there are certain tests that you just ran through three of them.

01:42:46.580 There are certain tests that you do, but things like an MRI and PET scan, she hadn't had any of

01:42:51.320 that. She ultimately had them after, after she died and she did have very, very serious disease,

01:42:56.060 but it's a tough diagnosis. And that's the world we live in.

01:42:58.740 Oh, so that CT scan that we see of her head that shows basically it's mostly fluid. There's no

01:43:04.500 brain matter. That was post-mortem?

01:43:07.020 Yeah, after. Yeah, that was after. Six months later, because then it all surged up again,

01:43:11.200 as you can imagine. So I talked to the neurologist. He just happened to be the last neurologist. I

01:43:16.100 personally, as majority leader, met with the brother. He was clearly going to be coming to us. The house

01:43:20.740 had already sort of called for the case. I talked to the family and the family said,

01:43:24.880 don't terminate her. I looked at the medical records again, just, just because I was curious

01:43:30.000 about it. And it was clear that she had not had an MRI, had not had a CT scan, had not done any of

01:43:34.740 the current things. Remember, this happened back in 1990. So I checked what I did. It was there now.

01:43:41.120 And so I checked with the Senate leadership. Harry Reid was a Democrat at the time,

01:43:45.240 became bipartisan. The house led on a bill. I'll come back to what the bill was. And we had a bill

01:43:52.240 and it was bipartisan. It was supported unanimously in the United States Senate,

01:43:56.520 overwhelming majority, both parties in the House of Representatives. And 15 neurologists had signed

01:44:03.900 an affidavit and all of that that said that she needed an independent current evaluation, that she

01:44:08.560 hadn't been evaluated recently. So really controversial, even among my staff. They said,

01:44:13.180 what in the world are we doing? And I said, I know, you know, but this has come to us and it's at

01:44:18.260 an issue that cannot be resolved. And I said, it should be rare. It should be decided locally the

01:44:23.960 way, you know, for 20 years in medicine that I'd been able to decide life and death decisions,

01:44:29.180 which I was in this field that you do. Bill passed unanimously in the Senate, in the House,

01:44:34.500 I think it was like 210 to 50 something, bipartisan. What it did, the bill itself guaranteed a process

01:44:42.480 and not an outcome. And so it basically didn't say, keep her alive. It basically said, she needs an

01:44:48.100 exam that is truly independent, not with courts and not done by politicians. And once that exam is

01:44:54.480 done, if she's in a persistent vegetative state, then remove the tube if that's what the husband

01:44:59.460 wanted. And if not, the family should be listened to, the extended family should be lifted to.

01:45:04.680 So the outcome, it passed the United States Senate, it went to the federal courts,

01:45:08.860 they denied the petition and the feeding tube was removed and she was allowed to die.

01:45:14.940 So that's the story. So it's an interesting one. And on reflection, you know, again, publicly,

01:45:20.820 I don't go through this and I've written some about it because I've written a lot about brain

01:45:24.960 death issues and persistent vegetative state. But as a policymaker, the story captures this

01:45:34.000 sometimes necessary conflict and this very real tension between the rule of law and the law basically

01:45:43.640 said, well, the husband can decide. And this broader consideration of ethics and morality

01:45:50.840 and in this world of increasing technology. And the ambiguity of not having any sort of thing written

01:45:58.620 down. So in retrospect, people ask me, because a lot of people say that's got to be the biggest mistake

01:46:03.340 you did in 12 years. And I say, I kind of just avoid it and move on. But in retrospect, the fact

01:46:09.920 it didn't come, I'd probably do the same thing and pass the same bill, set up a process and not an

01:46:15.020 outcome. And I was the only person in the Senate at the time who had taken two oaths. And one of

01:46:19.760 those oaths was to the Constitution, the life, liberty, pursuit of happiness, the oath that all those

01:46:24.340 62 lawyers and everybody taking the Senate. But I'd also taken this other oath, this Hippocratic

01:46:30.200 oath to protect life and to do no harm. And when there's ambivalence around that and when the

01:46:37.700 family wishes otherwise, and it's true ambivalence, I will opt on life and I will opt on what I would

01:46:43.960 interpret as life. Others may not. And this has got to be exceptional and rare. And it has been in

01:46:50.500 retrospect and those kind of cases haven't made it back to Congress. And these decisions clearly,

01:46:56.160 clearly, clearly are best made locally. The other challenge, I'll close on that, is the politics made

01:47:02.940 it worse because you had the Chris Matthews of the world who would go out every night and, you know,

01:47:09.360 big sort of Democrat and sort of after people. And he would he would say, here you have Senator

01:47:14.100 Prist, Prist playing doctor in the United States Senate. You know, he's one of those other Republicans.

01:47:18.940 And then the Republicans would shoot back from the House and say, oh, this is a great case because

01:47:23.200 it shows right to life. What I did and what I tried to do with these, and it's hard to do,

01:47:30.400 is to separate the politics from the policy, to separate the politics from the science.

01:47:37.080 And it shows, this case shows that this inherent tension and challenge to our policymakers who are,

01:47:44.780 whether it's at the state level or local level or federal level, are given our trust to make

01:47:51.380 decisions like this and to have appropriate oversight. The decision should be locally,

01:47:57.280 though, as much as possible. Yeah, I mean, I definitely agree with that.

01:48:01.780 My personal views, notwithstanding on this case, which is that I think that I can't understand how a

01:48:07.620 CT scan wasn't done, you know, in the late 90s, frankly, to have, you know, made it so obvious as to

01:48:13.340 what the state of her brain was. I think the interesting point here is that you were probably

01:48:18.540 the least political, in my view, in that, because that's the advantage of being in your final term

01:48:24.460 in a Senate when you've publicly declared you'll never run for another office, is you don't

01:48:29.000 technically have a political dog in the fight anyway. So even though your viewpoint was viewed

01:48:34.620 as political, I actually, I think it was, those were your personal views, and people are free to

01:48:39.940 disagree with them or agree with them. But I didn't think of it as necessarily a party view

01:48:43.720 because you, I don't think there was anybody in the U.S. Senate that had less of a stake in what

01:48:48.380 the party felt. That was just sort of, you were voting your conscience, and we may disagree with

01:48:53.880 that, but I don't think it was political. Yeah. And, you know, issues, all issues, and even with

01:48:59.760 impeachment back in the past, people have a hard time understanding that politics is a part of

01:49:06.620 our democracy. And you wish, and with things so partisan, everybody wished, not everybody, but

01:49:12.500 so many of us wish you could push this extreme partisanship out of it. But even things like

01:49:17.940 impeachment, there's a political nature to it. It was intended to have this political thing. And

01:49:22.660 politics and policy can't be separated totally. And that's why I come back to this tension that has

01:49:28.560 to be there, and this discernment, and this past experience, and not arguing, you know, the law to

01:49:34.040 the extreme that you can't see a larger picture because laws are imperfect as well. And that's

01:49:39.660 the sort of representatives that I think we need to aspire to and then elect and have people get

01:49:47.180 involved enough in politics that they can elect those sorts of people to these bodies of Congress

01:49:52.360 to Senate or governors or state assemblies. It's so hard to believe that we are now in the

01:49:59.440 20th year since 9-11. I want to go back to that Tuesday morning for you because I think anyone

01:50:06.540 can remember, you know, anyone of a certain age can remember every detail of it. But I can't imagine

01:50:12.620 what it's like to have been a member of the United States government at the time, let alone a senator.

01:50:18.580 What do you remember about that morning and what was running through your mind as

01:50:22.780 this thing was unfolding? I still have nightmares about it. We all have the anxiety, like we feel

01:50:30.160 with, you know, COVID and other things. But the nightmarish experience of having an assault

01:50:36.160 that we have no idea how big it is, how deadly it can be, coupled with being in a position of having

01:50:45.340 to make decisions at that point in time. You're a United States senator. The security at that time

01:50:51.140 rests 100% with the president and a co-equal branch of government, the Congress, and with inadequate

01:51:00.120 information, no information having to make decisions there. So the fright of it, my first thoughts when

01:51:06.380 it hit, I was out in front of the Capitol and over at another senator's office and the first plane hit

01:51:12.460 and I fly and fly a lot. And it'd be really unusual for somebody to hit a building, World Trade Center,

01:51:19.520 but it could be done or it could be a suicide mission. You even thought that during the first,

01:51:25.000 because when the first plane hit, I remember I was in the trauma bay at Hopkins and I remember

01:51:30.560 someone coming in and saying it and I had just assumed it was like a Cessna had hit on a foggy day.

01:51:35.740 Did you know that it was an actual passenger plane? No, not. At first I was in an adjacent room. I was

01:51:41.160 outside of the Capitol in an adjacent room and somebody just said, you know, should you stop your

01:51:45.740 meeting because the plane hit the couch? Same thing is what you said. Then when we figured out that it was

01:51:51.720 an airliner and then shortly thereafter, the second one hit. I was in leadership at the time. I was in the

01:51:57.600 top five of leadership at that time doing the senatorial committee. So at that level, you get briefings beyond

01:52:03.240 what other senators get. And then when you're a majority leader, you get different, higher level briefings.

01:52:08.420 So I knew that a lot was going on in the world and that there was a lot of noise on the internet,

01:52:15.900 but not nothing that you'd think about. But I knew the capacity that this wasn't just like a small

01:52:21.620 thing. This was really going to reflect the world. And then when there were two, always when there are

01:52:25.540 two in life, there's going to be a third in these sorts of things. And so that was it. So my first

01:52:31.040 thoughts were that. The second was, and at the same time, and probably really first were my kids,

01:52:36.640 because my kids were in school over in Washington, over near where the vice president lives. And

01:52:42.080 it's near the cathedral. And I knew if they're going after us to go after the Pentagon, they're

01:52:47.140 going to hit any sort of symbolic sites and that they went to school right there. So of course,

01:52:52.840 concerned and worried about them. And then that was it. Then there was this long period of time

01:52:57.360 where we got together and were shepherded to an offsite secure location. And people,

01:53:03.760 there's certain people in leadership that are identified. So if there is an atomic bomb,

01:53:08.300 or if something happens, we can refashion government. So those people are taken to a

01:53:13.680 secure location. A few senators, a few house members, a few Supreme Court justices, the president

01:53:20.680 or the vice president. And I was not part of that particular group, but it was at that level.

01:53:25.660 And it was as intense as anything in the surgery that had gone awry that I'd ever done. And I

01:53:34.380 wouldn't panic there. But this world of not having any information, no intelligence, essentially no

01:53:40.900 intelligence, and not knowing where it's coming from, and not knowing what was going to sue over

01:53:45.040 the next 12 hours, this is different than anything at the operating room, at the table. And there you're

01:53:49.760 doing life and death things every day. This was different.

01:53:53.640 Do you recall what you went through over the next two or three days? Because I think back to it,

01:54:00.680 and I've been thinking a lot about, as we approach the 20-year anniversary, the stuff I want to talk

01:54:05.960 about with my daughter, who obviously was born after. And in some ways, it feels like it was yesterday,

01:54:11.800 because there are things about 9-11 I remember as though they literally happened a week ago.

01:54:17.000 Like there are, you know, I remember exactly where I stood. I remember exactly what the TV looked like.

01:54:22.900 I remember moments that evening, because none of us left the hospital for two days. You still were in

01:54:28.000 a state of, are there going to be people coming here? Do we need to be here? And then there are

01:54:33.240 other things that are a total blur. So I can only imagine in your situation, that's amplified,

01:54:39.100 you know, 100x. But do you also have sort of pockets of that period of time that are

01:54:44.920 almost a blur? Or does everything still sort of fit, you know, nice and neatly and linearly

01:54:51.020 into your recollection of the weeks that unfolded from that?

01:54:54.660 Yeah, no, it's an interesting question. I think the difference was that we knew we had to act.

01:55:00.660 And the first thing that we needed to do quickly, we didn't know if this was a single actor,

01:55:05.600 a single state, a single group, a country, multiple countries. And we didn't have the intelligence.

01:55:11.700 And so once we found out we didn't have the intelligence, which was pretty quick,

01:55:17.840 we had to pretty much assume that we were going to all be taken out. And by us, it's not us. We

01:55:22.720 don't matter. But it's the United States of America. So you go after New York, you go after

01:55:26.780 Washington, D.C., you destroy the Congress, you find the president. So ours was how, in the first six

01:55:32.600 hours, eight hours, actually that night, how we could display to the world that this is terrible.

01:55:40.460 And unprecedented and has to be addressed. And so we said, how do you do that? So we all stayed at

01:55:48.100 the Capitol. We went to the front steps of the Capitol. And this is the sort of thing that does

01:55:54.600 bring Democrat and Republicans together. I mean, really closely together. Nothing else sort of

01:56:00.000 matters. We're talking about the safety and security of our country and maybe existentially the future

01:56:04.760 of our country. And so we went out. And I remember, obviously, the people you think are who are there.

01:56:11.860 The leadership was there, of course. And the people were there. But the John Lewis's of the world,

01:56:16.240 you know, spoke and we displayed to the world that you can try to take us out, but you can't take us

01:56:23.680 out. I think that was really important. We did that after the anthrax attacks. Other attacks, we sort of

01:56:28.600 did that. But I think it's really important to make that statement to the world, to stand strong.

01:56:33.180 And then it was, once we knew we could reconstitute government, if something worse

01:56:38.120 happened, it really was just sort of systematic of up and run. This is how much intelligence we have,

01:56:44.180 making decisions. Should we hit? How fast we should hit? Should we hit it all coming back? If we hit,

01:56:49.660 what's going to come at us next? So it was a busy time. And then I had family, as I said,

01:56:54.260 that was always in the back of my mind, just being in Washington, D.C.

01:56:59.160 One of the things that you said that really stands out to me is the amazing lack of partisanship that

01:57:06.960 existed for a brief window of time following the attacks of 9-11. And obviously, you could say,

01:57:13.780 well, it was an external attack directed directly at the United States. But does it surprise you that

01:57:21.660 a pandemic like COVID didn't have any of that effect of unifying the country? At least politically,

01:57:31.520 it doesn't seem to have done anything to have unified people. It's driven people further apart.

01:57:37.040 And yet, it's an enormous existential crisis. Do you think this is different because

01:57:40.900 a pandemic is not a nation state and it doesn't affect the U.S. exclusively?

01:57:47.500 I think when you can externalize your enemy or the assailant, it in some way brings people together.

01:57:58.560 You've got an image. You can create an image. They're out there. There's somebody. There's an

01:58:05.720 embodiment of something that is external to you that you can project towards and receive sort of

01:58:12.520 incoming on. When you have the virus itself, you don't have that because the virus is this cagey

01:58:21.160 little thing that knows no borders, that is truly global, that does not discriminate at all. And

01:58:31.220 there's no sort of externalization of it. There's no sort of setting it up and putting it on the table

01:58:35.840 and saying, let's do it. I think the other big thing, and there's no reason to get into the politics

01:58:43.320 of it, I think the leadership was different as well in our government. The communication was very

01:58:49.980 different. And that, to me, has been the most disappointing. When I look at the big assaults

01:58:56.860 in our country that were on our soil here, whether it was anthrax with 14 or 15 people dying here and

01:59:04.580 hit our Capitol, whether it is 9-11 and now the pandemic, my biggest disappointment has been the

01:59:12.840 lack or maybe just the difference in the type of leadership that was demonstrated. And it's

01:59:18.160 leadership slash communication, how things are articulated and the like. And I think that plays a

01:59:23.620 big role. I think that if there had been a call to action with appropriate communication, leadership,

01:59:30.660 trust, empathy, understanding that this pandemic could have been externalized and we would probably

01:59:38.060 have more rallying around it instead of this, you know, what you see on social media and the internet

01:59:44.300 and television, which continues to this day. In 2005, you quite accurately predicted what we're

01:59:53.120 seeing now. You referenced the 1918 Spanish flu and you said it was not a question of if, but rather

02:00:04.160 a question of when we would experience another pandemic, another virus specifically. You very

02:00:11.960 astutely pointed out that these 10 things are basically going to happen. There's going to be

02:00:17.380 complete and total social chaos. There's going to be supply chain disruption, boom, boom, boom, boom,

02:00:22.340 boom. And a pandemic preparedness strategy should include stockpiles of antiviral medications,

02:00:30.060 all of these other things. It's easy to blame one party or the other, but the reality of it is

02:00:37.360 no administration's really ever taken that seriously, have they?

02:00:40.760 People have taken it seriously. I'd say both administrations have, and this may come back

02:00:46.400 to where we started, that my experience coming in was colored by things like HIV AIDS, killing 3 million

02:00:54.280 people a year, was characterized by anthrax, which when it hit the Capitol and knowing the potential

02:01:00.940 of what it could do. The lack of preparedness was just crystal clear to me just based on my past

02:01:07.780 experience. And so what I did in 2005, as you said, 20 different speeches I gave, all basically

02:01:13.800 out the same speech, but I gave them on the East Coast, West Coast, Silicon Valley, the floor of

02:01:18.100 the United States Senate, far reaches like Nantucket, the Red Forest of California, everywhere. It was

02:01:24.840 essentially the same speech, as you said. It was called a Manhattan Project. It did predict it was

02:01:29.840 going to come because of this admixture of birds and animals and transportation around the world.

02:01:36.780 So it's clear. It's clear from a medical standpoint.

02:01:39.700 And just to be clear, you thought it was inevitable just from these factors, not necessarily even

02:01:45.240 bioterrorism. I mean, you were thinking that would be another potential way, but it was, yeah.

02:01:50.440 Okay.

02:01:50.800 Yeah. And I mean, I use the bioterrorism a little bit because I talk about that as well,

02:01:54.460 because you could intentionally manufacture any of this. You hook it onto a virus or hook it onto

02:01:59.320 smallpox where you have something that's real transmissible. And it's not that hard to do.

02:02:03.420 It's real easy to do. You can do it in a room, eight by 12 foot room with, you know, with simple

02:02:08.980 things. And so the bioterrorism at the time, because of, you know, 9-11 and all the things

02:02:15.400 that had gone on, it was clear we needed to worry about that, especially with smallpox because

02:02:19.980 Russia had a supply of smallpox they could use. But no, this was outside of that. This was sort

02:02:24.340 of coupled with that because the same things that you need are the communications, the infrastructure,

02:02:30.020 the stockpiling, the virology, the research and development, the antiviral agents, the

02:02:37.260 manufacturing capacity, all the things. These are all the things that, as I say them now,

02:02:41.740 people say, oh, yeah, check, check, check. That's with COVID. And the point is, and I called

02:02:46.560 it a Manhattan Project in each of these speeches. And as I said on the floor, I left the Senate

02:02:53.000 the next year and work has been done and people have tried to do pieces of it, but nobody has

02:02:58.060 really stayed on it. But the six proposals I testified before Lamar Alexander's committee

02:03:03.340 about the next pandemic about three months ago, because right now is the time we have to talk

02:03:09.880 about the next pandemic. There will be another pandemic. And will we be prepared? And we all

02:03:14.420 know, and especially political people, that, you know, it's only the snake that's at your

02:03:19.780 foot that you're scared of. Once the snake goes off in the trees, you just lose that sense

02:03:25.800 of sort of urgency there. So from the scientific standpoint, I mean, I wasn't any great. I mean,

02:03:33.020 we say this like I could see it. I wrote it down and I wrote what we should do and what

02:03:37.980 we should do, we didn't do. And therefore, you know, it's interesting to go back. My biggest

02:03:42.680 fear is that you write that same talk and you give that same talk or somebody does and there's

02:03:47.940 nothing done after that. And I don't think that'd be the case, but it's going to take,

02:03:52.580 you know, a, a constituents and people saying this is an existential threat. This, you know,

02:03:59.520 this COVID thing is, is not a deadly virus. I mean, I say that.

02:04:03.460 I mean, that's, that's, that's my fear, right? Is we kind of, and you say this and it sounds

02:04:08.420 horrible, but we dodged a bullet here. This virus is quite a wimpy virus relative to the Spanish flu

02:04:16.120 or the Hong Kong flu or SARS-1 or MERS. And there's a sweet spot. Obviously, if a virus is

02:04:24.120 so deadly that it basically knocks, like if it's an Ebola virus, in many ways, those are less

02:04:30.780 threatening because they kill people so quickly. But there's an inverted U shape of lethality and

02:04:36.960 SARS-CoV-2 is actually quite far to one side, which is it's so non-lethal that it's so contagious,

02:04:43.060 but you take its lethality up one order of magnitude. It still wouldn't, especially if

02:04:50.940 it has a long latency, it's a devastating virus. I mean, it kills tens of millions of people.

02:04:59.220 And I think you're absolutely right about the snake at your feet. Like there is a certain amount of

02:05:03.600 political capital that probably exists now in 2021 to really say, okay, well, what, you know,

02:05:12.140 how much money is the government willing to spend to make sure that the next time this happens,

02:05:16.660 we're not on our heels?

02:05:19.380 Yeah, exactly. And it's funny with Lamar's committee, he ran the health committee, was chair of it,

02:05:25.840 the health committee. And he took a lot of heat. I listened to it. I love not being there because I

02:05:31.000 can sit there and listen to the hearing and give my testimony. But, you know, half the people would say,

02:05:36.400 Lamar, this is crazy. Looking for the next pandemic, seeing what we should do. We've got a pandemic now.

02:05:41.240 And he said, well, you know, of course we do. And we're doing everything we can. But look what

02:05:45.840 history has led us to. And, you know, there are clearly things to do. But how do you get people

02:05:51.440 to stay on it and understand? And they're simple things. Infrastructure. Right now, the, you know,

02:05:59.440 things like vaccine distribution, which has been so challenging, you know, that's the sort of thing.

02:06:04.540 And public health infrastructure locally, there are fewer public health people on full-time payroll

02:06:10.400 in our communities today, wherever you are right now, than there were eight years ago.

02:06:16.400 Public health people. Public health has been the stepchild of health and welfare and healing.

02:06:23.460 That is, it's inverted now and people appreciate it. But we're going to actually deliver on it,

02:06:28.340 not just next year, and not just put more funding in it, but really do it over a period of time. And

02:06:33.400 that's the, that's the challenge. And again, why getting people to these bodies and opening those

02:06:40.300 bodies up to whether it's more scientists, more thoughtful people, people getting other experiences

02:06:45.960 from life and having them participate in supporting them in those positions.

02:06:50.180 So I want to kind of go back to just this broader topic of the political world we live in today

02:06:55.900 versus the political world you entered and left, which is in some ways not that long ago, but yet

02:07:01.200 seems like an awful long time ago, frankly. If you think about the historical arc of politics,

02:07:07.700 which I frequently try to do and think back to the worst of times, and maybe this isn't so bad,

02:07:15.340 but help me understand, you gauge your level of optimism for me in terms of this infrastructure,

02:07:21.200 right? Which is the two-party system, the systems that are in place that have rewarded the extremes

02:07:27.660 and punished the compromisers, the tools that amplify it, social media, cable news, all these other

02:07:35.280 things that we could, everybody can rattle off all the things that could be broken today. How optimistic

02:07:41.360 are you that if we can both agree that where things are today is suboptimal, it's going to get

02:07:47.100 better? Yeah, you know, I, I, um, my podcast, I ask people sort of the optimism question a lot and

02:07:55.920 90 out of 100 say they're optimistic about things. That's really interesting. And, and so I'm slowly

02:08:03.140 going to answer it because I think you have to be really, really careful on the, first of all, I am

02:08:08.200 optimistic. And again, it's my nature and I tend to get involved in things that seem to be challenging

02:08:13.420 and I, I love just working with them and bringing people in and things tend to work out pretty well. So I

02:08:19.860 feel good about it. I think the next few years are going to be really difficult and probably not get a lot

02:08:27.160 better and may get worse. I think if you look at structures that are contributing to it, we're going to

02:08:34.900 figure it out. And I don't blame social media, but it's an accelerant. And the way, you know, we are

02:08:44.120 going to figure out in some way to curate social media in a way that still allows, you know, freedom

02:08:52.560 of expression and free speech, but where it can't be used in the negative ways, whether it's in

02:08:59.440 partisanship or misinformation. I feel good about that. And part of it's in, in discussions with,

02:09:05.880 with people in the sort of Facebook direct world and the Amazon world and the Google world and the,

02:09:12.680 the Netflix world. It's going to take a little bit further, but I think we're going to get better

02:09:17.680 there. When we get better, that will put us in much better standing because if we're still on the

02:09:21.520 curve of getting worse, it may get worse in other, you know, this world populism, it may get a little

02:09:26.540 bit worse, but it will get better. And I'm, I'm optimistic about that. Leadership, I think it's

02:09:32.920 going to take a while. I'll tell you just a real quick story. When I, when I was in the Senate,

02:09:38.720 things are partisan. Again, we don't want to idealize the past, but President Bush and President

02:09:43.680 Clinton did not do this as much, but President Bush came in and we were in sort of this, you know,

02:09:50.620 9-11 sort of world, but came in and every other Friday would take three people from the Senate

02:09:58.560 leadership or four, two Republicans, two Democrats and from the House leadership and, and every Friday

02:10:05.320 do breakfast with them quietly, no press right off the Oval Office. And it was uncomfortable. You'd have

02:10:13.300 the, I shouldn't mention any of the names, but you'd have the people who are the leaders around the

02:10:17.660 table. And, you know, people like Nancy Pelosi and President Bush sitting side by side for breakfast

02:10:24.240 for an hour. There's a little bit of attention there, but I, and this was before the Iraq war and

02:10:31.360 things got really complicated in, in so many ways, but, but for that period of time, things seem to be

02:10:38.180 so much better, really uncomfortable. And people, I don't know if people have talked about that either,

02:10:43.860 but what I say that and preface that, because I do think if you have a president of the United

02:10:49.580 States, President Obama didn't do it and President Trump didn't do it, President Biden, it looks like

02:10:56.460 he would do something like that, but you know, you just don't know. But I do think if you had at that

02:11:02.300 level, not at the level of, of a Chuck Schumer and, and Mitch McConnell, you know, it's too ingrained

02:11:08.480 to there. But at that level, you pulled people together and said, I'm willing to lose my next

02:11:14.000 election as president of the United States. And again, take, take president Biden or president

02:11:18.360 elect, soon to be president Biden out of it. If you had somebody like that, who stayed with it,

02:11:23.780 it would make a difference. It gives cover for people below. It gives cover for the majority leader

02:11:28.860 and, and the minority leader and the, and the speaker and the democratic leaders in the, in the house.

02:11:33.480 And that's not that hard. I mean, that kind of makes it sound simple to do, but sort of my experience

02:11:41.440 in my thoughts, it could be as easy as that to begin to turn the tide. And I think we'll, we'll

02:11:48.220 see that. I don't know if we've been the short term or long term or how long people will be around,

02:11:51.940 but it takes that sort of courage to do it, to say, I would, you know, I'm willing to sacrifice

02:11:56.740 a second term or something like that. That's a big sacrifice though, isn't it? I mean,

02:12:01.880 that's not something to take lightly. Yeah, it is. But, you know, it's gotten to the point that,

02:12:06.540 you know, how you elect somebody who really will do that from a very partisan group, it's makes it

02:12:12.000 hard, but it's doable. And we're talking about regular people and, and, and people who, you know,

02:12:17.300 can be reasonable and not always, it depends on the individual. But for those two reasons, I'm

02:12:23.280 optimistic because I think it can be done. I think it probably will be done, but I, and it can be done

02:12:27.660 pretty quickly. I think there's a real call from people, uh, uh, for this sort of bringing people

02:12:34.680 together. Doesn't mean sacrifice your principles and it doesn't mean sacrifice your party. It just

02:12:38.980 means come to the table and be able to have a discussion and have a disagreement and leave,

02:12:43.880 you know, as we did sort of more in my first term than in my second term in the Senate,

02:12:48.740 sort of shaking hands after you have a big debate on the floor of the Senate.

02:12:51.680 You know, there's so many other things I wanted to chat about and we're really,

02:12:55.140 we've gone a lot longer than I thought we would to this chapter, but we really have only covered

02:13:00.460 a couple of the chapters of your life. There's an entire chapter that follows what you did in

02:13:05.320 the Senate, which is in some ways the busiest chapter of your life in the last 15 years.

02:13:12.180 I guess just for the sake of brevity, what has been the most interesting project you've worked on?

02:13:19.780 Because you've, you know, you're, you're doing venture capital, you're on the board of

02:13:23.940 for profits, not for profits. You're a part of the bipartisan policy center, which is an organization

02:13:30.860 I'm quite familiar with and quite impressed with. I mean, your commitments span so much.

02:13:37.520 What has been the most interesting? And I guess, what have you brought from the two previous chapters

02:13:43.460 to it? Yeah, that's a great question because people, it's a little bit like they look at you,

02:13:48.260 probably, if you look at your past, that, you know, you've done different things and you've

02:13:52.820 tried different things. And is there any sort of narrative or thematic that sort of goes through

02:13:59.220 that? And for me, it goes back, I'm sure, to this whole image of healing and health and hope and all.

02:14:08.100 And, you know, it sounds a little bit gimmicky and all, but it does come back to that. In my mind,

02:14:13.560 learning to be a doctor, sort of practicing the transplant world, that was 10 years learning and

02:14:19.420 10 years delivering and then 10 years and 12 years in politics and then 10 years in sort of

02:14:25.300 the private equity world and then the last five years in venture capital. All of it's around health

02:14:31.820 and healing. Everything I do, everything. And so what I did when I left the Senate, I said, now,

02:14:37.240 what is the next step? And, you know, smartly said 12 years in the Senate. So I said, putting

02:14:43.680 together my past experiences, what if there's one thing that could be done to change the course of

02:14:49.780 history? I think, you know, this is thinking big and it's not the sort of thing you tell anybody at

02:14:53.700 the time. What would it be? And, you know, based on 20 trips to Africa and the global experience and

02:15:00.520 all and HIV AIDS globally. And I came back to one thing and it was K through 12 education

02:15:07.880 and globally, probably K through 12 education for girls. And if you're going to spend, you know,

02:15:16.680 a increment of time with my experiences, where would it be? So what I did is start a foundation.

02:15:22.960 It's called State Collaborative on Reform of Education. It's by far the biggest thing in the

02:15:28.320 state now. I started, but got really smart people and good people, dedicated people to run it.

02:15:34.460 And with that, it has had an impact where Tennessee has, for the last 10 years, shown dramatic,

02:15:42.000 dramatic improvement in K through 12 education and been recognized as such. So that is a little bit

02:15:47.940 out of healthcare, but the nexus between health and education is so real. The health feeding into

02:15:55.460 being better educated, the more educated, sort of the better health. It just feeds together and I see

02:16:00.440 it and, you know, the data is good. So that's sort of the one big bucket that I've made a conscious

02:16:06.040 decision. If you look in the investing world, what I do is focus on mission-directed health service

02:16:12.280 companies, not pharmaceutical companies, not molecules, not devices, not, you know, all of

02:16:18.560 that. And so I start around companies. I start companies and support companies that have a mission

02:16:26.360 of taking people, usually vulnerable populations, and lifting them up. And the one that I'll just

02:16:32.680 mention, because you asked for one, is one that kind of comes back to the things we've talked about

02:16:37.840 is palliative health care. In our country today, most people do not die the way they would want to

02:16:46.180 die. Hospice, the last seven days, four days, three days is really good in America, finally, after,

02:16:53.300 you know, 50 years, is really good. But in this world of chronic disease, where people are living,

02:17:00.780 and as you described so well in your talks, you push that downslope on the chronic disease and

02:17:06.260 aging out as far as you can. But at some point, you come to those graphs that you draw, and you're

02:17:12.040 going to bring things to a close, and it's chronic disease. So think of it, that last year of life,

02:17:16.520 that last eight months of life. And it's called palliative health care. In hospitals, traditionally,

02:17:22.540 if you're at Vanderbilt or Stanford or Mass General, or your local hospital, of people listening today,

02:17:29.600 you can get good palliative health care. But if you live 30 miles away, or 50 miles away,

02:17:35.040 or 100 miles away, you can't. And you're sitting there with a chronic disease, you're going downhill,

02:17:40.320 your family, if you have family, local, they don't know what to do. And so what we did is create from

02:17:46.280 scratch a company that focused and is now the largest palliative, non-hospice-related palliative

02:17:55.480 health in communities in the country. And it started with this full circle sort of thing.

02:18:02.600 It started with when I mentioned that I had hundreds of people being referred to me back

02:18:07.180 in those early transplant years, right over here at Vanderbilt. They were coming in, but I could only

02:18:12.100 transplant one every four or five days. I didn't have enough donor hearts. So I had 50 or 60 people

02:18:17.040 coming in who were going to die within six months, flying in, coming in, saying, we need a transplant.

02:18:22.320 And I said, I don't have enough donor hearts. And so I had to learn how to take care of them,

02:18:26.700 prolong their life, and getting the stuff right, the nutrition right, the exercise right, the mental health,

02:18:34.580 the spiritual health right. All of a sudden, they started living not just six months.

02:18:38.700 You know, they wouldn't come here if the doctor hadn't told them it was going to be six months,

02:18:41.580 but they lived eight months, nine months, 12 months. So seeing that, and then I lost my mind and went to

02:18:47.780 the Senate. And then I got out of the Senate, I came back, and we're still in the same place.

02:18:51.720 Nobody had developed a palliative health care system for the last year, eight months of life

02:18:57.740 that looked at the spiritual, that looked at the mental, that looked at the nutritional,

02:19:04.020 that looked at the exercise and sort of general acute care, medical care as well.

02:19:10.020 And so that's sort of a good example of the sort of companies that I believe in. It ties things

02:19:15.900 together. There are needs that are out there, and there are lots of other areas, you know,

02:19:19.640 like that out there. The area of the frail elderly today who don't need palliative care

02:19:25.460 is doing another company right now, just a year old, because they've got social determinant,

02:19:31.920 $35,000 of that cost plus $35,000 of medical costs, but nobody's put all that together to treat

02:19:38.240 them holistically. So anyway, those are the sort of examples that are exciting to me that are really

02:19:43.820 no different than the innovation of the new ideas and the execution, which is most important,

02:19:49.640 of doing a heart transplant and figuring out how to, you know, some way figuring out that cardiac

02:19:54.620 biopsy to determine inflammation and then developing a new drug like cyclosporine, which revolutionizes

02:20:01.600 that field. It's doing it in the business world where you have access to capital, you can move fast,

02:20:07.060 you're not slowed down by government. So it's pretty exciting.

02:20:10.480 Bill, if ever there was a Renaissance man, you are that man. And I still think in many ways,

02:20:16.420 I know you don't agree with the idea of term limits, and maybe that's not the answer, but

02:20:19.700 there really is something to be said for having people in the government who haven't spent their

02:20:26.220 entire lives in government. And I don't know, I think the trajectory of your career is very

02:20:30.620 interesting, and maybe we'd all be better served if you were still in government, although I don't know

02:20:34.320 that you'd still want to be in government. I can tell by the look on your face, you're probably glad you're

02:20:39.460 not. Yeah, I'm just fine.

02:20:43.800 No, it's been a pleasure speaking with you today. And I, uh, thanks, thanks for all your service.

02:20:48.100 Oh, great. It's really a tremendous honor to be with you. And the stories we talked about, I,

02:20:52.740 I really haven't told and, and discussed, but because of my huge respect for the nature of your,

02:20:58.540 your podcast, uh, it's a real honor to be with you. Thank you.

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The Peter Attia Drive - February 22, 2021

#150 - Senator Bill Frist, M.D.： A modern Renaissance man's journey through science, politics, and business

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