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

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My guest this week is Senator Bill Frist. Senator Frist is a former transplant surgeon. He's a pilot, though we don't even get into that in this episode. It's just a whole other amazing story. Obviously. Politician, businessman, healthcare policy expert. I mean, he's truly a renaissance man. As you'll see. He graduated from Princeton and Harvard Medical School, went on to study at Stanford, where he learned transplant surgery from the pioneering transplant surgeon of our era, Norman Shumway, before heading over to Vanderbilt where he created the largest transplant program east of the Mississippi. He did that till the early 90s when he up and ran for the US Senate in 1994, having never held public office before. And perhaps even and more remarkably than that, he was elected as the 18th Senate Majority Leader in 2002, taking him from the single least senior person in the US Senate to the most senior person. We spend a lot of time talking about his journey through medicine and ultimately 12 years in the Senate through some of the difficult policy decisions and the controversial decisions that were made. Since leaving the Senate in 2006, Bill has done a number of things. He sits on the board of more not for profits for profit companies than you can count on. Probably spent a decade really focused on private equity, before now shifting his attention to more venture based funding. He also hosts a podcast called A Second Opinion and we get into about two thirds of what I had wanted to get into here. That's how much I wanted to talk about. But it's really a remarkable discussion. And one of the most interesting things about Bill that we do touch on here is that in 2005 he effectively called the pandemic. He really laid it out through his experience in studying HIV and creating policy around hiv. He was an instrumental part of pepfar, which we talk about as well, and also his experience with the anthrax scare post 9 11. And he basically looked at these examples, coupled with what he saw on a lot of his travel to Africa, which he had done as a physician, and basically said, look, it's not going to be a question of if we have a major pandemic, it's a question of when. And these were the things that needed to be in place, and these are the likely things that are going to happen. And unfortunately, a lot of those things came true and we weren't really ready. So we spend a little bit of time on that. And finally we talk a little bit about just the current state of politics. And even though this isn't a podcast about politics, I think most people in the current environment can't help but acknowledging that we're in a bit of a strange environment. And we talk a little bit about his optimism as to how things might get better in the future. So without further delay, please enjoy my conversation with Senator Bill Frist. Bill, thank you so much for making time to sit down with me. I know today was you had a lot of things going on in your personal life, so I appreciate that we didn't reschedule this, but it would have totally been understood if we needed to.

Great to be with you, Peter.

By the way, it feels weird calling you Bill. I always feel like I need to call you Senator Frist. But the first time we spoke, you were adamant that I call you Bill. So I'll tell you a funny story. When I left residency, I had such a hard time not calling people Mr. So and so, just because, you know, you talk to your patients that way, right? Like, you know, Mr. Jones, Mrs. Smith, we're here to talk about this. And then when I got out in the real world, people were like, you know, you can just call people by their first name. Was that a difficult transition for you?

You know, there's two things come to mind. Number one, most common thing I get do you get called Senator or. Or doctor? You know, people who want to be formal. And of course I say call me Bill. But that is a harder one because in the Senate, you know, especially today, people that's kind of down on the respect world and doctor is still pretty much up there. So, you know, I say, well, doctor, but you're supposed to call senator, etc. Etc. But then I remember going to Mass General up in Boston, being from Nashville, Tennessee, and being from Nashville, I called everybody out of respect. Mr. If they were two, four years older than me. And it may sound crazy to a lot of people, Listen, that's just sort of the Southern way of doing it. And I remember going in, working with a cardiac surgeon, and right in the middle of the case, I said, yes, sir. And you're not supposed to say sir either. It's kind of like the mister. And then he turned around and said, don't you ever, ever say sir to me again. Isn't that funny? It says it depends on where you are. You're exactly right.

At what point did you realize growing up that you wanted to be a doctor, let alone a surgeon?

You know, I had a real sort of fortunate circumstance in that I was the last of five children, and my dad was a family practitioner, a doctor. And my older brother, who was 15 years older than me, went into medicine, so he was a doctor. My middle brother ended up going into cardiac surgery, so he was in this track. And so I pretty much assumed I would go into medicine or, or nursing or the healing profession from very early on. For that reason, I saw the gratification. I saw the way when dad would come home at night, what he would talk about in terms of healing and giving people hope. So that was just always stuck in my mind. I thought about other things. And when I jumped up to college, I majored in public and international affairs. When I tried other things, I always came right back to the healing profession in some shape or form.

So when you were an undergrad, you were not a pre med, and Princeton's pretty well known for international affairs and things, so you were kind of in the epicenter of where one would go to study such things. But that didn't sway you from medicine, did it plant a seed that ultimately there would be more for you to do than medicine?

You know, in high school and in early years of college, I interned in Washington, D.C. for Congressman Joe Evans from Tennessee. At the time, I spent a summer writing for a newspaper, the Nashville Banner, no longer a daily newspaper here in Nashville. So throughout it was always being interested in the broader aspects of medicine, of being a doctor. And I had no idea, and I didn't have any master plan with it. But I guess at every stage, and now that I look back, it gets reflected in my life that I always had other parallel interests going on. And as you probably know and recall, I'm a little older than you are. It wasn't all that popular at the time when you were in medical school to have these other interests, you know, to basically say, well, I want to go write an op ed on some technology when your professor is sitting there of medicine and basically the only thing in the world is medicine. So it was always challenging and not being in a pre med track at Princeton, but still wanting to go to medical school. You know, even the medical schools had a little bit of bias about coming in at that time. Very different today if you didn't demonstrate working in a lab and all those other pre med track things in those college years.

And so what was it like for you? Mass General obviously is one of the pillars of American medicine. If my memory serves me correctly. Isn't Mass General the second oldest hospital in the United States or is it the third oldest?

I don't know. But it's there and the tradition is all there as well.

And so you've got this northeast training and then you go way out west for training in cardiac surgery. What was that experience like back this would have been early 80s that you went out to Stanford?

Early 80s. And it's actually interesting in many ways, mainly in retrospect, of course, but I went to Harvard Medical School and then I did the six years at Mass General and did my cardiac fellowship at Mass General. But when I was just entering that fellowship, it was fascinating from an ethical standpoint that that the community there had decided with the board of trustees of the hospital that they were not going to do heart transplants. And you know, I'd kind of stayed at Mass General because they'd done the early kidney transplant work in America there had great immunologists. And then I was 10 years into this and then all of a sudden the board of trustees and the broader community said it's too experimental, it hasn't proven itself. We can vaccinate a million people. I'm exaggerating a little bit for the cost of one transplant and therefore they put a moratorium.

Now what was the mortality at that time? Because Bernard's first heart Transplant was in 67, 66.

67 was when Christian Bernard down in South Africa did the first transplant. And then after that there were a hundred done in Texas. And then most of those patients died. So it's kind of shut down.

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

Another fascinating story. And Norman Shumway, who was my mentor at Stanford at the time, was really outside of the mainstream of cardiac surgeons. And you know this, but again, bringing our listeners in a little bit. He had worked diligently for about 10 years in the laboratory, figuring out this heart transplant world systematically with discipline, not taking it to people until they figured out the science. And then Christian Bernard came in he watched a little bit of this. He was from South Africa, and more in an opportunist way, he said, well, 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 it. Shumway, from that mid-60s to when I got involved in the early 80s, systematically had a program where other programs would do 100 or 50 or 30, like out in Texas, and then they would just leave it totally because the patients died. Well, somebody would ask the question, why are they dying? He would figure it out. So he was doing about 10 a year or 15 a year, and figured out the science of it, the immunology of it, the cardiac biopsies, the instruments of it. And in a very deliberate way. And I tell that long story because it really had a huge impact on me, that the science is really fundamental. It's important. Until you get the science right, you should not be taking this to the clinical world. Know the facts, get rid of the misinformation, do clinical trials. Don't prematurely take things to the field. And so at Mass General, they saw a 50% mortality, very expensive procedure of this moving hearts around and the immunology and the equipment that was required. And they said the greatest good for the most people is to not do heart transplants at Mass General or Peter Bent Brigham or Beth Israel or Boston City. To me, from my perspective, I said, are you kidding me? You know, we have the opportunity to, in a very ethical way, figure out heart transplantation in a way that can save hundreds of thousands of lives. If you don't get a heart transplant, you die within six months. If you get it, you can live 10, 15, 20, 30 years. People I transplanted 28 years ago were still alive here in Nashville and around the country. So I got fed. I didn't get fed up. I did get fed up. But instead of staying at Mass General, I said, I'm going to California to train with this one person in America who systematically had spent 20 years developing heart transplantation and continued to do that because the overall field, the overall heart transplant world continues to evolve.

I mean, to me, it's just such an amazing story within medicine to go back to the first transplants within kidney and then to look at heart. And in some ways, liver was almost the most ridiculous of them in terms of the complexity of it. You know, I don't know if you have, like a bucket list of people you wish you could have met or interviewed who are no longer alive. And I'm sure you probably met Thomas Starzl, but if I think about people I wish I could have met, Thomas Starzl would be very on that list. I don't know if you ever read his book Puzzle People, but I can't recommend it highly enough to people who love stories about the history of medicine. To me it sounds so much like what you describe Shumway doing, which is systematically in the face of non stop failure, watching bad outcome after bad outcome after bad outcome. But in patients for whom there is no other choice, I mean there is no such thing as an extracorporeal liver. So if a person is in liver failure, they are going to die. There is no temporizing measure. And I don't remember the numbers because it's been so long since I read it, even for the second time. It's a book I've read twice. But one thing that stuck with me when I read it, which is one is the belief that you have to have, that this is going to get better and two, just the personality trait that says I'm not going to get broken by short term failure after failure after failure because I'm seeing some other progress. And whether it is, look, we're making strides in the immunology because back in the early 80s, what was your two, what was your immunosuppressive regimen? I mean, prednisone and MMP. I mean, what, you didn't have much.

Yeah. And it comes back and we're seeing it today with today's technology, which is even moving faster. But these great breakthroughs which require this deliberate thinking in the spite of these challenges that seem insurmountable, there were technological, mechanical ones like doing a cardiac biopsy. All these patients were dying early on because the heart would reject, get inflamed right afterwards. And so then the typical surgeon would walk away from that and say, I'm not doing this. Shumway said, okay, let's figure out the inflammation. So developed an instrument that you can go through the neck into the heart. Sounds terrible, but it's real simple. Can do it in three minutes. And figured out how to address the inflammation, to diagnose it and treat it. And then the medicines that you mentioned when I started in the transplant world and success was not that good. Early on it got better. But we were using two drugs. One was called prednisone or steroids that most people have taken or understand. And the other is imuran. And we didn't have a new drug that came along in about 1982, which is cyclosporine. When you added that drug, which was serendipitously discovered from a fungus over in, I think, Sweden or Switzerland, when you added that to the cocktail, all of a sudden mortality, which may have been at 50%, went to 20%. Just that one addition. Because if you can adjust the immunological treatment and make it where it's not as severe, you don't push down the immune system so much where people would die from infections. But I think the important point in all of this, which I think you're leading and I'm sort of feeding into, is that science is this evolutionary process and that the greats, the Starzl, Tom Starzl, University of Pittsburgh, did all transplants. But the world icon leader in liver transplants, which was about two or three years behind heart transplants, and the Norman Shumways of the world had that deliberate, that discipline, that focused process in taking these insurmountable challenges that were impossible to do, and systematically, over a period of time, capturing the best of the best, even when there are lots of losses along the way, ultimately be successful.

This is just kind of a broader historical question of surgery. When you think back over the last 150 years of surgery, the modern era, right? And you think about the Giants, right? The Blalock's, the Halsteads, the Shumways, Linehan, Starzl. I mean, these people, they had step function changes in the field, their existence, and the teams around them, right? When you talk about a surgeon, you have to talk about the critical care staff, the anesthesiology staff. I mean, no surgeon can do what they do alone, but they fundamentally changed surgery. Do you believe that there are any more step functions ahead in surgery? Are there sort of from a technical standpoint or combination of technology, medicine, instrumentation, like, is there something that you think is still an untapped opportunity in the way that, you know, we're talking about what Shumway or Starzl did, for example.

Yeah, you know, that's good. The transplant world's a dramatic world that we've talked about where I would go take a heart out of one person who was brain dead and then replace a diseased heart and a living person totally. And even me describing it is pretty gross. I mean, it's brutal. I mean, you're talking about lifting a heart out of somebody and putting it in there. And I say, yes, I've done it hundreds and hundreds of times. And then people say, this doesn't sound right.

It is amazing, though. I mean, it's worth pausing on that for a moment, it is. It's hard to believe. And I haven't participated in nearly as many as you, so maybe it gets old after a while. But it wouldn't surprise me if every time you did it, it still felt magical. It probably never wore off. In terms of what you just explained, it's profound.

Never. I think you don't have to have faith, really. People will jump to that immediately. But the idea of me getting a call, not me. This is done by everybody now, at that time, not that many, but now it's done in every major hospital around. But getting a call, flying off in the middle of the night, taking a heart out of somebody, putting it in a bucket with ice around it, and then putting it on an airplane, traveling for three hours, coming back, opening up a patient and spending 45 minutes, put the heart in. It's just like a piece of meat you're setting in a chest, and then you just step back, and as you warm the patient up, the body up, all of a sudden that inert piece of meat that you've been carrying, it's terrible to even describe it that way. All of a sudden, slowly, that sort of magical moment, it would begin like a bag of worms just kind of moving around, and then, bang. All of a sudden, it would start beating rhythmically, you know, 70 beats a minute and pumping blood throughout the body. And then that patient goes home a week later. And, you know, it's miraculous. So I agree with it. And you can't fully explain it, but it is. But it took the Shumways and the Starzlls and people like that to do that. And then my generation, which came right beyond that, and then beyond the transplant world, there are other great innovations you remember, and I don't know exactly when you were doing your surgery, but taking out gallbladders, we used to do these big incisions and come in these bloody feels and hip replacements. I mean, all that's been revolutionized through scopes and minimally invasive surgery. So that will probably continue in more robotic surgery. But I think the really exciting things will be at the cellular level of regenerative medicine. Instead of replacing that heart, keeping that old heart in the person, injecting some of the cells in there, understanding what the Human Genome Project delivered to us back in the early 2000s with some manipulation, having those cells that you put in there liven up and energize the dead cells that are there, that kind of breakthrough is going to really be exciting coming forward. So is that surgery or not? I'm not sure. It takes things down to almost the synthetic biology world, which to me is where things are really exciting in terms of, at the level of the cellular interaction and surgically putting in, whether it's mitochondria, a lot of the things we're talking about with COVID and vaccines and all today, that's sort of where so much of the future is, I think.

So when you got to Stanford, was Bruce Wright there or had he already left for Hopkins?

He was leaving at exactly that time. At that time at Stanford, as you know, there were four cardiac surgeons and Shumway, the cardiac surgeon who was father to them all. Most of the people had gravitated there because of his approach being outside of the norm. Not a lot of respect for tradition, for tradition's sake. Big believer in team approach. In Boston, you have to work 10 years to get put in a stitch. You had to wait your time on the east coast if you were good at it and you were a first year intern, if you were a fourth year medical student and Shumway saw you operate, he would let you do what he wouldn't let a resident with 10 years of training do if you could do it. So it was more kind of merit based there, all of that approach. And so that was the culture that he built. Huge respect for nurses, huge respect. It wasn't about him, it was about the people around him. He said he was the world's greatest first assistant. And for those who don't follow surgery, the first assistant is the person who's across from the main surgeon who kind of helps the main surgeon do the work. And what he was saying, basically, it's not about me, it's about us as a team. And Bruce Wright came out of that tradition and he had just left and of course didn't know him well because he went, went to Hopkins after that.

So you, you finish getting your, you know, basically your transplant training at Stanford and then you head back to. Is it Vanderbilt? You, you go straight to. Yeah, yeah. And, and you serve there on the faculty for quite some time. And you're building a program, obviously, right? There was no transplant program. Yeah, you're building it.

No, yeah. At that time we had the Stanford program and there were a few other programs around, but east of Mississippi there were no established real programs in Tennessee, there was no heart transplant program. So built a program on the model of Stanford in heart transplants. And I want to come back to where you're going, but once we mastered heart transplants, this whole field of lung Transplants three years later had never been done, never been successful. But because of that drug cyclosporine, we were able to do that.

That's what Bruce and Norm did together. Right. They did the first heart lung transplant.

They did heart lung lung. Ironically, you have the heart.

Lung lung is harder.

Yeah. So you have the heart. It seemed like taking a lung would be easier, but it's not. So the combined heart lung, where you take them both, and that's what Bruce Wrights and Chumway did and that's what I brought back to Vanderbilt.

Was there any resistance to this, given what you just described on the east coast being kind of a bias towards, hey, this is still very costly on a cost per life basis. There's probably more efficient things that we can do with resources. Nowhere in this have we talked about where insurance companies are. How are insurance companies thinking about this type of a procedure?

At that time it was interesting. So insurance and the payers, you have Medicare, government, Medicaid and then you have the commercial payers. At that time it was still investigational. So Medicare, our government did not reimburse for transplants. It was regarded as experimental for about eight years. And they did a very smart thing. They designated certain centers to figure it out and then once the survival was sufficient and you were qualified as a center of excellence, then they would start reimbursing you. The payer system was a little bit the same thing. And I was again lucky and I wouldn't have come to Vanderbilt if it hadn't been that far. Sort of thinking ahead, they basically said, bill, to get the program up, you've done scores and scores of heart transplants. You were trained by the best for your first 10 transplants. Because we know this is that important, just the opposite of Mass General. We know this is life saving to thousands and thousands of people dying across America. We also know that it's not 99% successful. But what we'll do for your first 10 transplants to get your program up and running, we will cover you if the insurance does not. And so that gave me enough to. And we did maybe six and then it started being reimbursed. And then over a period of about eight years, every commercial payer, Medicare and Medicaid began to reimburse because they had the out 100% mortality. Everybody would die who needed a transplant. Everybody would die within six months without it. And if you got it, you on average 80% of the time would live at least five years. And if you got beyond that would live 10, 1520 or 30 years.

What was the pressure like on you during those first transplants? I mean, here you are. It's one thing when you're at Stanford and you're under the umbrella of Shumway and this incredible environment he's built, which, as you said, you've got the best anesthesiologists, you've got the best nurses, you've got the best perfusionists. Like, everything that is needed to support that program, you have the best of. And the culture is already there. And you're a fellow within that system. And now you have to go out and hang your own shingle, and you have to now train everybody to do what you took for. I'm not saying you took it for granted. Right. But what one could have easily taken for granted at Stanford. And all of a sudden, now you're the operating surgeon. You don't have Shumway first assisting you, and you don't have a lot of time to figure this out. You can't take 50 transplants to get it worked out. Do you remember what those first few days were like? I mean, that must have been unbelievable stress, because it's two stresses. It's the obvious stress of I got to save this person's life. But there's a bigger thing at stake, which is enough bad outcomes, and this program gets shut down, and we don't know what that means for the future of transplantation.

Yeah. And there was an additional burden that at that time, Shumway was training the great cardiac surgeons. They weren't great. They were young people like me at the time. But just like Bruce Rice, who we talked about, he didn't send them to Hopkins, but Bruce came out of this very interesting culture where team was very important, where humility was very important. That's juxtaposed the way most people think about cardiac surgeons who are in there. You know, high pressure, type A throwing instruments. You never saw that. And so when I came to Vanderbilt, east of Mississippi, Bruce was up in Hopkins. All of a sudden, all over the country, people said, why don't we go to these guys instead of going out to California? So all of a sudden, within. Within a year of me being at Vanderbilt, starting a program from scratch, I was getting referrals. Hundreds of people coming in saying, I want the Shumway approach. Shumway says, you're as good as he is. That's the way he would talk coming in. But to answer your question, it comes back to what I threw in about Shumway saying he was the best first Assistant. I came here and there was a guy by the name of Walter Merrill. Walter Merrill was Hopkins trained, excellent surgeon, pediatric surgeon, adult surgeon. He could do it all. He was gifted, the most humble person in the world. And Walter had come out to Stanford to watch me operate, to kind of learn about the program for Vanderbilt. And so we had this dialogue and from day one, for the next 10 years, there wouldn't be a transplant that we did. And we did hearts and heart lungs and we did lungs and we did infant transplants. We were transplanting kids or babies at 2 days of age and 3 days of age. There was never a transplant that I was involved with that Walter Merrill wasn't there. Linked side by side, sort of this alter ego. And with that and building the team with nurses and profusionists to sort of share this same Shumway mentality of team first. Keep it simple, stupid. Don't be afraid to double dribble. If you don't get it perfect the first time, go back and do it again. And it's worth saying all that a little bit because I want to jump ahead a little bit because that program after I left has continued to grow 10 years, 15, 20 years later, to where that program today is the largest heart transplant program in America. It does more heart transplants than in any center that people are listening to us in their cities today. And it has nothing to do with me really, but it's taking that experience which again you understand what the residence experience is and the young faculty is if you're lucky enough to have a mentor and you can capture that culture and you go out and apply it. So I replicated exactly what I saw at Stanford to get it up and running those first two years. Worked with a great team and then with that we were on the cutting edge of the early lung transplants, the early heart lung transplants. And then ultimately obviously we added liver to it and we had bone marrow already, we added pancreas and became a large multi organ transplant center.

Now where was Debakey and Cooley in the midst of this? When did the big Texas centers participate?

They were early and it fits with Texas and they were great surgeons and you know, they are up there and they would say they're, they're above Starzalin in Shumway just because their egos were, their egos were big and they were excellent surgeons and they did these incremental leaps in surgery and in vascular surgery. Both of them, they were in the same town in Houston, Texas and they, which fits with the ego, the Confidence and ability jumped on transplants. As soon as Shumway did the first one in America, Christian Bernard did one. A few months later, Shumway did one. And then Shumway was going to continue along 15 a year. The way he was doing it, deliberate, let's learned iterative process. But DeBakey and Cooley said, well, listen, this thing looks pretty good, seems to work pretty well. And so they did in Texas. This is all in the late 60s. So remember, this was all 67, 68. And between 68 and about 69, they did, I think, 110 heart transplants in competition with each other. Do it big, do it Texas style. And then all those patients died. And they died. Which comes back to the story. Shumway was out there figuring out how to treat the heart rejection, this inflammation, using that little cannula he puts through the neck. And they didn't have the patience for that. And so they shut their programs down and went on to other things. And then in the late 70s, started doing a few. And then the 80s kind of picked up where everybody else did.

I mean, the whole story of DeBakey and Cooley, I don't know if there's a book about it, but if there is, I'd love to read it. The rivalry between them is unbelievable, right? I mean, it's two legends in cardiac surgery, both of whom will tell you that they're the greatest of all time. Did they ever reconcile before debakey? I think debakey died first, right?

Yeah, they did. And the hospitals were right across the street and never did, really. I think when DeBakey or Cooley got a medal of honor, that there was some kind of congratulations that went on. But in essence, never, never did.

Yeah, it's interesting. I never met DeBakey, but I met Cooley because he trained at Hopkins. And so every night when you're on call, when you'd be walk through the Blalock hallway, you know, Hopkins is such a storied place. Like, it just. There's never a piece of tradition that's not enough, right? And you'd see these pictures of the young Denton Cooley, and he was just upsettingly handsome, right? So sure enough, we're at the American College of Surgeons one year, and each, you know, as, you know, every university or every medical school has their own thing. So you'd go to the, you know, you go to the Vanderbilt one, and you'd probably go stop at the Stanford one, and you'd go stop, stop at the MGH one. And so at the Hopkins one, Cooley shows up and I'm there with my closest friend from residency who happens to be a cardiac surgery fellow, about to go and embark on his pediatric cardiac fellowship. And Cooley was talking with both of us and he says, oh, what year are you in? And I think I was in my third year or something. And he says to my friend Jorge Salazar, what, what year are you in? And Jorge says, well, I'm in my ninth year because that's, you know, at the time. By that point, it's nine years just to do adult cardiac surgery. And then he said, and then you're going to go off and do pediatric cardiac, I think is another two years at ucsf. And he's like, gosh, that's just unbelievable. I mean, back in my day, it only took six years to become a cardiac surgeon. Now, admittedly I was better than everybody else and blah, blah. And he just went on. But he said it completely seriously, like there was no irony in that statement. And we got such a kick out of that. But I guess there's some truth there. I mean, he was a gifted surgeon.

Yeah. And he really, they're icons and contributed so much. And they're, you know, hundreds of thousands of people alive today because of people they've trained and procedures they've done and really amazing icons in that field of cardiac surgery. They probably, they won't ever be anybody like them again. And cardiac surgery has changed so much. It's one of the reasons. But they were just too talented, prodigy type surgeons.

Do you think that that medicine can no longer attract that caliber of individual? Like, has the profession changed such that the best and the brightest would never consider medicine today? I'm not close enough to what the hotshot college kid is doing today. But, you know, given, for example, the incredible changes we've seen in technology, is it really, you know, the case that the coolies and the Debakeys and the Shumways of the world, if they were 20 years old today, would be going to Silicon Valley or would be going to Boston and going into biotech startups. Like, you know, there are other ways to serve people that don't involve literally going into medicine. And I. Do you ever think about that? Like, is there, is there, has there been some sort of passing of the torch in terms of the war for talent?

You know, when you think of the Starzls, Debakeys and Shumway and the great surgeons, you think of great athletes. You think of the athletic part of it. In part, they're using their hands. You got to be fast, deliberate, you got to keep it simple. You got to be right. And I think because of technology, that's less important. I think the fact that we're operating through telescopes and soon microscopes. When you asked your earlier question, that the sort of athletic, competitive, hero on the field, cowboyish sort of approach, I think we're beyond that. Just most of the big sort of blood and guts that kind of imagery has passed by. But to go back to your question, no, I think medicine still, and maybe in some ways even more so because we've opened up this whole world of biology, synthetic biology, and at the cellular level, the regenerative medicine and the, the use of stem cells, all of these things are going to attract, and they're going to be, they're going to go in as medicine because they want to heal, they want to be a part of something bigger than themselves and not just behind a microscope. That I think it's going to continue to attract great, great people. And if you look at, at least here at Vanderbilt, where I'm familiar with medical school applications, they're at all time high right now. And people say yes, but the quality is not there and the attraction of making a lot of, of money or doing the next Uber or Airbnb is out there. I think all of that's right. But I think we're going to continue to see and maybe even see an increase in the overall quality of people applying to medical school and then going to medical school and then entering these fields.

I'll ask you the question I get asked all the time, and I think you can answer it with frankly, a far better lens, which is what advice do you have for somebody today who wants to go into medicine, doesn't quite know how they want to do it, based on all you've seen and what you see in the future, in the landscape. And now we're getting ahead of ourselves because we haven't got to this part of the discussion where we're going to talk about policy and things like that. But given what you know about the profession of medicine and also the landscape of payers, hospital systems, consolidation of these things at risk versus not at risk, reimbursement, all these things, what do you say to somebody? Do you say, go forth and conquer? Do you say, here's a hedge that you want to have in place? I mean, what advice do you have for somebody to be successful?

You know, where you started is probably still my philosophy. And I'm still active in teaching here and mentoring a lot of People in medicine and in health. And I think staying broad, I kind of fell into that because I knew what my track was going to be in medicine and therefore I wanted to do journalism and I wanted to try the policy world and wanted to go to Washington and wanted to write about technology. All at the time I was going to medical school. Then it was harder, as we said, because there was a stigma almost against it. And today I think the professors in medical school understand that the best, whether it's on the social side or even on the technical side, the best are people who bring broad experiences, have the curious mind that isn't narrowed down to just one area, to just cardiac surgery or just bypass surgery or valves, but has that curiosity throughout life. So I still continue to encourage people to live as broadly as possible to develop those interests, to look for your talents and if they're outside of medicine, figure out some way, either as a hobby or something on the side, or write an article every week about it to keep that going. And I guess because I have jumped around so much and kind of changed career 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 healing and it's all giving hope. There's lots of different ways to do it.

Let's fast forward a little bit to call it the early 90s. Do you have a sense at this point that you want to make a run for Senate? Or how were you starting to think about a transition into elected office?

It's interesting. My goal was never to be in the United States Senate, ever, ever, ever. And I'd spent right at 10 years learning all this surgery and medical school and how to do transplants and how to do surgery. And then about 10 years here at Vanderbilt and we built a transplant center, a multi organ transplant center that was a great foundation for the future. And then I just began to ask myself, I did not serve in Vietnam, which a lot of people just right above me had done. I had not been in the service, I had not done anything actively other than learn to be a doctor and spend 18 hours a day doing it for those years. And I said, given that I was running a large transplant center and doing a lot of good, I felt what would be the one other thing that one might do to affect health, maybe not of an individual, but health of a community or health of a population. And I said, well, do you go run a university? I'd been on the board of Princeton University as a young alumnus and sort of saw the power there and thought about that. No, because I just don't think I can reach quite enough people. And so I systematically eliminated doing anything. I knew policy could do it because policy could affect the world. And I'd seen that back 20 years before when I'd been an intern during the college years. And so he said, the only place is really the United States Senate. I have a job. I know what I can do. But if you could get to that position. Not to change health care, necessarily, not to. At the time, it was Clinton care and all sorts of political issues. And it really wasn't for that reason. It really was an extension of what I saw as a little boy when my dad would come home, and that was in the days they had doctor's bags, and he would sit down exhausted and say, you know, the greatest gratification has been able to give somebody hope. And all of a sudden I said, policy can do that. And so I jumped. And nobody in my family had ever served in public office. Nobody had run for public office. They were not overly partisan. My mom was probably more of a Democrat. My dad was probably more a Republican, and I was probably neither. You know, I was just out there doing heart surgery every day. So it really was an extension of that earlier pull, probably genetic in some way of wanting to serve and that being a way to serve a population. And, you know, it sounds kind of patting yourself on the shoulder now, in retrospect, but that was what was going through my mind, and I didn't have anybody to look to. My dad said, are you crazy? And he's no longer alive. He died 20 years ago. But he said, you know, you're at the top of the world in surgery and innovation and running a large laboratory and writing papers. And, you know, why would you leave that to go into this world of policy? And the answer then was what it is now. I also said I wasn't going to stay forever. I said, you know, I'm not a politician, and I love policy, and I want to affect change and I want to innovate, but I only want to go do it for 10 years. And that's how I took the leap.

The Senate is the highest piece of Congress, so to, you know, I could. It's almost easier to understand if you said, look, I'm going to go run for the House of Representatives. I don't know how many seats are there in the House of Representatives in Tennessee?

Nine.

Okay. But to sort of say, I'm going to be one of the two people running for Senate is kind of remarkable. How long of a process was that? So the election was 96. When did you have to get serious about this? 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 have to leave. But you either do it or you don't. And this is the advice I give people, if you're going to get, go all in. So probably about two and a half years before I started talking. The problem I had is my parents didn't really buy into it. My family really didn't, because it's kind of hard to understand. So who do you talk to? And there hadn't been a physician elected to the United States Senate, 100 people, two from every state. There hadn't been a physician elected to the Senate since 1928. So I didn't have anybody to call or go see who'd gone through this eye of the needle, medical school and internship and residency and fellowship and practice. And that made it hard. And maybe that was a good thing. They may have said, get out of here, don't do it. But that was hard. And so I systematically took about a year this way. I'm still practicing. And I went to see Howard Baker. He'd been majority leader of the United States Senate before, a centrist. I went and talked to Lamar Alexander at the time, who had been governor, but he hadn't been in the Senate. I ultimately recruited him to run for the Senate and went and talked to Al Gore at the time, who was a senator, and had great conversations. And my fundamental question was, am I right or is this just like, you know, dreams? And to the one they said, it's a tough business. Half the people are going to hate you all the time and half are going to like you, and it's going to be very different than medicine. But if you're really serious about it, you ought to do it. Howard Baker, who was just an amazing guy and again, he was also from Tennessee the first time he didn't listen to me very much, or he politely did the second time politely. And then about the third or fourth time I went to see him, he finally said, okay, you must be interested and go ahead and make the jump.

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

No, he was still. He was right during that period of time. And that was going to open up a seat actually in Tennessee. At the time he was still in the Senate because this was in the early 90s.

Oh, this is before 92 then even. Wow.

Exactly. And this is all 91. And then ultimately that seat opened up and then I had an option of running for that seat, which is an open seat's easier to win because you got two people in there that nobody knows and it's sort of a flip of the coin. Or the other seat. And I don't know exactly why, but I went the less traditional route and challenged an incumbent. And I know why, because I was the fresh face and he was the person who'd been around for 18 years. But it was unconventional to go that route at the time.

So you ran in 94 against the incumbent, is that correct? Yeah. And you won by a pretty hefty margin, correct?

Yeah, I had a primary with six others.

Yeah. I was going to ask you about the primary. What was the primary like back then compared to, for example, what primaries are like today, which is a fight to the extreme.

Thank goodness it's not today where people get pushed out. Tennessee until recently, and it's changed in the last four years. But until recently, Tennessee had produced senators that were in the center. The eastern part of the state was more Republican. The western was more Democratic. The middle, where I live, a sort of of in the middle. So if you were versatile enough to move through that state, your politics tended to be very principled. And it might be principled Democrat or Republican, but you're pretty much going to be appealing to a broad range of people. So in our primary, there were six people all out of that same ilk. My disadvantage was that I was an outsider. I hadn't played my political dues with the Republican Party. Number one, I was from middle Tennessee and not east Tennessee and that was it. But the race was very different. And in that primary, just interestingly enough, was the person who I ultimately recruited to the United States Senate, Bob Corker. And Bob Corker and I, he was an outsider and I was an outsider. He and I were in the primary. So it started at 6, came down to 2. All races are tough races. He always say that ours was a clean race and ours was 100% cleaner than these races today. But it's hand to hand combat, this politics stuff. And so I don't want to over idealize the way it was, but we were out of this extreme sort of polar opposites where in a primary somebody's driven to the either extreme right or extreme left.

Do you remember what the main policy issues that you were running on in the primary and then ultimately in the general, that year in 94.

And that comes to the other thing. So, and because ultimately one which nobody had expected, nobody chances were probably one in 100. And the other thing that did happen, that it didn't start that way when I jumped in, but at the end in 1994, ended up being a lot of Republicans coming in. So I was part of that wave. I was still the least expected. I was the only person to be an incumbent United States Senator who came in and so ultimately won. But there was the luck end of it being at the right place at the right time as well. And so the policy issues, ironically when you look at today, were balance the budget over time, eliminate the debt, keep taxes small. So those were sort of the big issues. There were these big fiscal issues that were out there. Welfare reform form was just talked about in that period of time. Ultimately the bill passed about three or four years later. But those are sort of the three big issues.

And just to go back to the first point you made, what you're really saying is, look, in 94, two years into a president's term, the opposite party generally has a tailwind at that first midterm election, correct?

That's correct.

For example, I remember in 2010, two years into Obama's term, you get a little bit of that tailwind for Republicans and vice versa. So this in 95, four was the, the same thing. Now, how did you learn the Mechanics of the U.S. senate? I mean, I got to tell you, I find this stuff really interesting, Bill, just in part because I grew up in another country and I have a, an inferiority complex. Like I didn't learn US History growing up. So I, you know, my, you asked my daughter, she's like, dad, why are you always grilling me on US History? And it's like, hey, I, I'm trying to learn this stuff with you, but oh my God. Trying to figure out what the whip does versus the minority leader versus this and what, you know, what this means in this bill versus that. I mean, it just strikes me as when you go straight into the US Senate, that's like going straight into the major leagues, never playing aaa, double A and Little league baseball. Like, how do you learn all of that stuff? I mean, was that the scary. I mean, if, if the first time you're doing a transplant by your yourself as scary, I would think the first day you're sitting on the floor of the US Senate is ten times more scary.

Yeah, it was. I guess when I was first 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 win. So that the worst part with the 1st, the November to January equivalent, 22nd or January 4th, not knowing what all this is about. The Senate doesn't have a Robert Rules of Orders. There's not a book you read. There's a little book of rules and you'll hear, you know, you hear about it every two years. They have to pass the rules, but it's like a 30 page book. The real book is precedent that's set and precedent is experience. It's being around it's age, it's knowledge. It is, you know, all the other stuff that I had, you gave me a 30 page book. It's like in medicine or going to a new rotation in your residency, you just hop in and do it 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 month. So that would have been easy. The challenge of the Senate is that it's not a book that you can read. And I had the disadvantage of not having anybody I knew in the Senate either. No friends, no sort of colleagues. In retrospect, that's all a real deal. I was able to come in as an outsider, as a physician, somebody who is looked at to be trusted, somebody that is looked at to be fair, somebody who learns predominantly, not the way a typical politician does, that I know better than you. It's I gotta listen. If the patient comes in the door, which I'd done for the previous 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 say anything until they give me that chief complaint or that last look or question as they go out the door and all of that, which is second nature. It's part of being a physician or being a healer or a nurse. Is that listing that empathy component is part of the culture, but really the being it is in the DNA of physicians and nurses and counselors and healers. The room I walked into had 63 lawyers, 63 lawyers. I walked into that chamber and that chamber, every chair was full with somebody who for 10 years had been arguing legal cases and all. And so you'd say that's a disadvantage. Again, it ended up being a pretty big advantage. And I didn't realize it at the time, but by listening very carefully, by working with trust and upholding that trust, by, because I came in with this image and the reality of being a physician, people would come to me and they'd say, what do you think and what is your look on this from the outside? You've been around patients every day, 20 different patients every day for the last 20 years of your life, and you've listened to them. I've been in the United States Senate about as far from real people as you can get. All of that came as real advantages. And I, and again, I didn't know it. There hadn't been a doctor there, I told you, since 1928 or elected since 1928. So that was it. And kind of stuck with that throughout. But it wasn't health care issues. When there was a health care issue, it would all come to me immediately because at the time health care was probably, I don't know, 16% of our economy, and yet there was nobody in the chamber who had ever taken care of a patient or written a prescription or been involved at all. And so that kind of information gravitated toward me as well.

You know, you mentioned that 63% of the Senate were lawyers, 1% physicians. It's probably a dated statistic. So I don't know what it is today, but I can't imagine it's far from this. But the last time I looked at the stats, when you looked at the entire Congress, both the House and the Senate combined, lightly less than 1% had any training in secondary education. So whether it be an undergraduate degree in science or an advanced degree like yours, why do you think that is?

Well, you know, it's interesting. And then right now there are three physicians in the Senate and so I kind of broke the glass ceiling and now it's been three or four and in the house there are 14.

So it's clearly more than what it was when I.

So it's more. But if you look at historically and you sort of start now and go backwards in 50 year increments, I won't exaggerate, but I'll give you just the image. In the first 50 years of our country, the sort of 17, sort of 50 to 18 or 1810, there were, I think 25 or 24 physicians in the Senate over a six year period in and out. If you look at the next 50 years, 1800 to 1850, it was 12, about half of that. And if you look at 1850 to 1900 was about half of that. And then 1900 to 1950, it was about half of that until it got down to one. So it hadn't always been that way. But over time, as medicine got more specialized, as some of the stigma that we talked about earlier, that if you're in medicine, even if you could look at policy with the ama, the American Medical association, you're not a serious doctor. That was kind of the stigma. So people were discouraged and doctors wanted to focus on their work and therefore they didn't put themselves out there. And then even after I got there, you know, physicians don't support the political system that much. They don't get involved in the policy or politics. And I think it's been to the detriment of patients in America because physicians are the best voice for 300 million people because they're listening to their problems and their challenges and the socioeconomic and the diversity issues. And so they should be more interested. And so I don't think it's really that the body itself had an aversion to them. It's really that people from the science world didn't move in that direction. And there are good reasons not to. I mean, it tears your life apart. I mean, you give up all your privacy, families are destroyed. You have 50% of the, the country hating you, not hating you, exaggerating.

Well, certainly today, today you really do.

So I can't fully explain it, but I can tell you with the sort of issues that we are confronted with today and the issues that I ultimately, even my 12 year period we addressed, I was not the lone voice, but I spent a lot of time explaining what science is. And if science was progressing and technology was progressing, ethical issues were involved, they would gravitate naturally to the person sitting next to you if they happened to be a doctor on the chamber floor. There'd just been too few of them. I would say over time.

When you think about that first term in the Senate from 94 to 2000, you alluded to it earlier. You came into this saying without any ambiguity, you were hoping to serve two terms in the Senate not a day longer, and you were never going to seek higher office thereafter. Why were you so confident to make that assertion? I mean, most people who would serve in the Senate would want to maybe keep their options open and say, you know, look, maybe if things go well, there's, I'd stay for a third term or I'd seek higher office. Why were you so adamant about this 12 year limit?

Yeah, I actually told the people of Tennessee 7 million people Al served for 12 years. I've got a job. I believed very much in a concept called the citizen legislator. The concept that somebody goes, it's at the federal level that goes, they leave their home, they leave the People, they stay in touch with them, but they go to Washington, D.C. to serve as a citizen legislator. The citizen, the broad experiences, the trials, the tribulations, the challenges, the. The understanding, the empathy and applying all that to help shape the laws of the land. And then after I've done that, go back and live under the laws that I've passed or we've passed. And that's just a philosophy. And I believe that today, not for everybody, but I think the majority of people in the Senate benefits from it, and I think people benefit from it. Not to get locked up in this very almost encapsulated environment of the Senate or the House of Representatives itself. It was just clear to me, and that perspective came from medicine, the breadth that a clinical person has in taking care of acute medicine and chronic medicine and mental issues in the transplant world, you're taking care of all of that, that the world is much broader and that you've got a job to do, and after it's done, leave, let somebody else, and maybe brighter, smarter, or bring their citizen legislator experiences there. So it was a philosophy for me and the right one to do. It did allow me in my last term to focus on, instead of fundraising and having to cast votes in a certain way that looked politically good and that sort of thing, which is just part of the business, it allowed me just to have a clean slate, do what I thought was right, and move ahead.

So would you endorse the idea of term limits? I mean, this idea, if we just said, look, no senator can ever serve more than two terms. No member of Congress can ever serve more than six terms. If you wanted to keep it equal at 12 years. I mean, I've heard many people suggest that that could be one piece of the remedy to some of the situations we find ourselves in. I mean, personally, I find that to be a very appealing idea.

And initially I did, too. And you asked about those first days going in and. And I think of those first days just as an aside. My dad, who was a doctor, came up to visit me and he said on my door, it said, Mr. Bill Frist. Another one said, the honorable Bill Frist. And there's these gold plates on the door and on your chair on the Senate floor. And he walked around, he grabbed me by the arm, he walked me back down the hall and said, son, Bill, I love the fact that you're in the United States Senate. I may not have wanted you to be here, but you need to change that. Take that tag off and put Dr. Bill Frist there. And so that Whole world of being a senator for a period of time, sort of renting, occupying the office, but not owning the office was one. To answer your question, no. I think term limits would be a huge mistake of the United States Senate. This job is complicated, and it's equally complicated. Complicated to heart surgery and other things that I've done, the breadth of knowledge to be really good at it. And you can't know everything, but ultimately, every law of the land, every federal law of the land is going to come through you. Everyone. And that is really tough. The procedures we talked about, the rule book and the books of precedence and the things that aren't written down when I came in, and then jumping ahead with, when I got into leadership, all of a sudden, who did I turn to? I'm not smart enough. I'm sort of average sort of intelligence overall, and I work really hard. And so I would turn to the person who'd been there for 18 years or 24 years, and I would ask what it was like 20 years ago or 25 years ago. What is the precedent itself? And not go to some staff member who's 25 years old, who's very good, but hadn't been around. And that would not have been possible. That would not have been possible if there weren't a handful or 20 or 30. I don't know what the number is of people that are there. And so the system works pretty good when you have this crucible, this mixture of people like me who say, I'm not staying any longer, or Bob Corker, who I helped recruit to the Senate, who said, I'm just going to stay for 2012 years and then go back and do other things. But I do think this admixture is important because of the complexity of the.

Job in that first term, what was the camaraderie like between parties? You hear stories of, I'm in the middle of reading a book about Abraham Lincoln right now, and maybe these books somewhat romanticize it. But obviously there have been huge swings in sort of how partisan the country has been. But there are these periods of time in which politicians of opposite parties still socialize together. There was still a degree of respect that existed. Even if you disagreed on policy. As you kind of alluded to it earlier, you might spend The Week in D.C. without your family, and that would be a time when these would be your colleagues and you'd go home on the weekend sort of thing. I mean, what was that environment like? And how much time did you spend with members of the opposite party, your own party and what were those relationships like? And above all else, how did that influence your ability to bring your empathy to the side of, hey, I understand another person's point of view, even if I don't agree with it.

Yeah, it's really important. And like you, you don't want to over romanticize the past and recent events. You're asking the same question. Is that the way it's always been or is this brand new? And the first six years and the last six years were different for me. I served under two presidents, one a Democrat, President Clinton, and the other President Bush, or with them. And it wasn't because of them, but it was because of in part media and because of the, in part the Internet. In part, initially it was cable tv. As we had more of this sort of real time, nothing could be done behind closed doors. If I wanted to take a trip called a Codell, a fact finding trip to Africa, and I've spent a lot of time in Africa, I would take and go on a trip with four Democrats, senators and four Republicans and we would go to four countries in Africa and we'd be together, we'd travel together, we would share meals together, we would have discussions together. And over the period of sort of that 12 years, but over a period about four or five years, that became the junket. And so every New York Times, Wall Street Journal, anybody would come and say, you're spending taxpayer dollars by having a vacation over in Southern Sudan.

Anybody who's been to Southern Sudan knows that ain't a vacation.

Yeah, no, exactly. But it's easy when you're in this sort of fully exposed media world in real time where it's hard to counter everything. And so that really contributed a lot. So early on, probably the first four years, a lot more of that, having dinners and these aren't like Georgetown parties and all we're talking about in the Senate dining room sitting together. And then over that 12 year period, much, much less of that. And then it's gotten much, much worse since then. I'm still very close to a number of senators and it's gotten much, much worse since then. But the trend began to change right through that period of time.

And really the scrutiny of the media played a role in that. Of course the critic will argue, well, isn't that the job of the media to bring the critical eye to it? I mean, what is that balance between the media holding politicians accountable versus actually creating a counterproductive environment where it polarizes everybody more and creates distance between them? How do we think about this.

Well, we're seeing it play out. And I think you're exactly right. The transparency is critically important in past politics has played that out in our history, that hiding things in the long run is unhealthy and destructive to our government, to the fundamentals of our democracy. I think what changed it all is that what we're seeing today, more, more than even when I was there, but is the misinformation that campaigns, if the media like on this whole thing of codells being junkets, make the accusation, there's no way really to counter it. And if misinformation is put out there and it's in real time, and again, this is the period of time before Twitter and before Facebook and all. But if you put the information out there, it was much harder to counter. But it was same sort of stuff was that it was misinformation that was there. Therefore, the institutional structure, the corporate structure of having one lunch together, which we used to do, Democrat and Republican, ultimately evolved into the Republicans going to one room and Democrats going to another room, something they already did for business. But that joint room of getting together disappeared. And that's unhealthy. And there are ways that you can fix that. I won't jump ahead with that, but there are ways that you can fix. And it does have to be fixed. And it comes back to this. Being a doctor, I think the empathy word really does come back to this. Connectedness doesn't mean you have to agree, but this connected of seeing two sides of things and there's just less empathy in the corporate structure of the United States Senate today.

What committees did you sit on in your first term in the Senate?

Yeah, it's interesting. I sat on the Banking Committee, actually. I had been on the board of a bank, ironically, before. It's not the reason I went on it, but Pete Domenici was on it. And when I was choosing my committees, the way committees are chosen, I was 100th in seniority, so I had 99 people above me.

Were you the only freshman Senator elected in 94?

No, there were others elected, but the ones if you've served in public office before. Got it, you get credit for it. If you've been a governor, you get credit for.

Yeah, yeah, yeah. So you are the lowest totem pole.

Yeah, I mean, I thought I was okay being a heart surgeon and taking care of people and saving their lives. When I got up there, boy, they could care less. Especially when it came to committee choice or it came to anything that had to do with appropriations or Power, that sort of thing. But the committees I ended on were great committees. One was the Banking Committee. Fascinating time. And always a good committee has no power per se, but a really important committee in terms of constituents back at home. And the HELP Committee, the Health, Education, Labor, Pension Committee, which is health. And that did include things like I chaired the subcommittee on Disability Policy and, you know, for the whole United States of America, every law of the disability world had to come through that particular committee. And then went to Foreign affairs about two years later and stayed on that throughout because I had done so much travel to other countries doing medical work and it fit there. But those were the ones in the first few years that I was on and learned a tremendous amount. And then in the last four years, six joined the Commerce Committee and the Commerce Committee. That was the time there was telecommunication and all of the great reform that was going on then.

I've resisted asking you this question before because I wanted to ask you for the first time during this discussion, how is it that someone so young and so junior in tenure can become the Senate Majority Leader at such an early time in their tenure? So I guess walk me through the late 90s. You're obviously going for reelection. You won by quite a healthy margin. But what were the string of events that allowed you to go from being still a relatively junior senator to being, you could argue, the second most powerful person in Washington after the President.

Yeah, it's an interesting sort of line narrative in large part because that was not my goal. And if you're going to start with 100th in CRT and jump to number one in a period of six years, it sounds crazy and it is crazy. And Lyndon Johnson did it, but he'd spent all those years over in the House of Representatives. But to come in, by the way.

LBJ was, I mean, generally considered one of the most effective Senate majority leaders. I mean, some people still wonder how he actually managed to take the Vice presidency as such a step down. And of course, how history would have been different had he not.

But yeah, yeah, but the sort of sequence of events was I won reelection at the time there, Bob Dole, who is just a iconic leader as well, and Trent Lott and others were sort of the. Trent Lott represented a younger generation, but all very senior to me, were sort of added to each other and competitive, sort of the intra family politics class office sort of stuff. And I didn't pay any attention to that, really what I was interested in. And I use this in different ways today now that I'm out of politics. If I'm on a board, I like to go to the nomination committee that the future of a body, of an institution. If you really say, how do I want to affect a board, a nonprofit board or a for profit board, or the United States Senate, 100 people, the best thing to do is to get involved in the determination of who's in the room and who is not. And therefore in leadership, the sort of fourth or fifth position down, depending on how you look at it. In the Republicans, say there are about 50 Republicans. There is a more political position called the National Republican Senatorial Committee, but they're in charge of the 33 elections that one person is. And they get selected by the body to choose the next generation of senators. Not choose them, but you recruit them. And you know, I recruited Lamar Alexander, I recruited Elizabeth, I recruited John Thune. Maybe they would have ended up there, but maybe probably for most of them they would not. And so I ran for a leadership office then. And that leadership again I did. This wasn't I came there to do policy, to pass big stuff that would help people in health and welfare and lift them up in education. So I said, let's do that position for two years, then I can come back and do policy the last four. And so that year, six years in between six and eighth year, we did what you implied or you suggested earlier. I ran that group. I represented the United States Senate in every state. I had to raise money for the Senatorial Committee. But we won that year. Eleven seats, 11 Republican seats. It was the first midterm of George W. Bush. As you said earlier, there's a huge bias for the Democrats to win.

Right. But 9, 11 shifted it, I'm sure.

Right. You know, it was all sorts of macro, everything coming in. But we won and we won big. And so I worked it hard. And again, being a heart surgeon, you're not trained to do that sort of thing. But I traveled and I recruited people and I'd go to New York, I'd go to North Carolina, I'd go to the Nebraska, I'd sit down with 10 people who wanted to run for the United States Senate. I'd spend hours with them. I'd talk to their families and their spouses and say yes, and say this isn't going to work out for you. And then I have to raise money as well, state to state and say this is important to support these campaigns. And both parties have this is the.

Expectation at that point that if you broke even, that would be a victory to not give up seats in your first midterm?

No.

You were going. You were in it to win it?

Yeah. No. Well, no, the expectation was it's very unlikely to even break even in the first midterm of any party of the president. Just, you know, just historically, nine out of ten times loses seats. So I wanted to keep the losses to a minimum. I wish I could say it was to a break even. But we won and we picked up seats. And with that I developed a certain credibility among my people. People weren't jealous of me either because I'm just a doctor doing his best. You know, good guy, can bring people together, can bring the Democrat can beat the Republican together. But, you know, and by historical precedent, not, you know, nothing great in the family started breaking down and without going into details, there was a lot of dissension in the party and it was most of it was behind closed doors in these caucuses. And when it came to elect the majority leader again, I didn't want to be majority leader. It wasn't my goal. In fact, if you go to be in leadership, it's hard to do big policy. It's hard to do the sort of things I ended up doing. Hiv, aids, pepfar, these huge things that affect millions of people. If you're the leader and you look at what McConnell, whoever's the leadership, Schumer and McConnell today, and whoever it was will be, you know, as people listen to this in the future, they don't have time to do the legislation or the policy they're out there managing, hurting these cats being the 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 spend four years herding cats. But when it came down to the election, there were five people who wanted to be majority leader and all of them to be majority leader, you had to have a majority vote. And one might have 12 votes and one might have nine and one might, one might have eight and one had four and six. And then you get together with other people and I wasn't a part of any of that. But then it got down to where nobody had the votes. And people came to me and I had a group of people because I'd come off these Senate races with credentials. They said, well, what about you? And then all of a sudden all four of the other people came to me and said, if you will do it. They said, I can't win. And if you are interested, we want you to be majority leader. So I haven't really told that story Publicly, but I think it is important for people to. It humanizes the place. You know, this is no different than elections in life and things are fair and things are unfair and luck is a part of it. But that's it, that's the story. It did not have the credentials, didn't want. It did want the two year job so I could go back to policy. But the two year job did well, but got lucky, really lucky and won. And then at the end of the day, in part because of this doctor thing, they also saw me as somebody that is non threatening. They said if this guy comes in, I want to stay here forever. They would say to themselves, this is my job. This is my pinnacle in life. And my pinnacle in life is doing heart transplants out the window, going to Vanderbilt and saving lives every day by just doing my job. But this was the pinnacle in life to a lot of people. And so they probably said, well, you know, if I give him my people and I work with him for four years, when I leave, I might be the one that he says should be.

The next majority leader, as you alluded to earlier, these next four years, while you're Senate Majority leader are quite busy and potentially one of the signature things you're a part of is pepfar, which you've alluded to. Now I've always found it interesting how little Americans understand pepfar and yet when you talk to people in Africa, it's a very different picture you get there. Right. I mean, I think when you go to the parts of Africa that have been impacted by it, they hold the administration in such high regard and yet for some reason it doesn't get, I think, the attention it deserved domestically. Do you agree with my assessment and if so, why do you think that might be the case?

I partially agree.

You know, Tetbar, let's start with telling people what it is. Yeah, yeah, let's.

We talked about HIV, AIDS and it makes sense being the only doctor in the Senate, that people would come to me early on. And I had spent years going to Africa, spending two to three weeks a year taking care of people, doing surgery, training people. Worked with a group called Samaritan's Purse initially and then other groups on my own and throughout Africa, mainly in south central Sudan and a province called the Louis Province there, but also in Ethiopia and South Africa and Botswana. And I would see people dying there a lot. And there was no testing for HIV AIDS at the time. And then I came to the United States Senate and worked with President Clinton and President Clinton said, yeah, it's a big issue. And we put maybe a couple hundred million dollars into it, but never did anything about it. And then this right wing, not really right wing, this middle, but right wing, George Bush came. And President Bush, this is 2000, had never been to Africa that maybe he'd been one time when his dad was president for a night in conversations with him and other people. Tony Fauci, who everybody's heard a lot about today, was a huge part of it. I'd bring pictures back of people dying of HIV, AIDS, but the story at that time was that 3 million people, 3 million were dying every single year because of a little virus that in 1980, in 1981, we didn't even know what it was. We had never seen it in the United states. But with 3 million people dying of that and a couple of million dying of tuberculosis and one of malaria, this was by far the biggest killer globally of a disease. And so President Bush basically listened to the stories focused on it, sent Tony Fauci down to Africa. You know, is this something we can do something about? He came back in a surprise way at the State of the Union Missions 2003 when I was majority leader, I knew it and probably five or six other people knew it, basically said I'm going to make the single largest commitment to a single disease that's ever been made by a president of the United States. This little KG virus, hivaids. At the time, Republicans and faith based people thought it was a disease of gays and was bad. And the Jesse Helms of the world basically said it was a call from God and punishment and all the left wasn't doing anything about it. But they talk about it but nobody would step. So President Bush, I wrote the Senate bill and I. But a lot of others got together and passed this legislation about six months later and record time jumping ahead, 20 million people are alive today because of that five page bill that surprised everybody coming out of this president.

And it's no small figure. I mean we're talking, you said, you know, Clinton put 100 million into this. I mean your bill put $60 billion into this, if I'm not mistaken. Is that right over.

We were spending about 200 million a year. And again President Clinton was right on all the issues. And later after he left office, as you know, made a big issue about it and still has done unbelievable things to the Clinton foundation for it. But at the time there were just so many other things going on. So spending about 200 million and then that first year with President Bush that We got it through the first year, $3 billion, and then $3 billion a year for five years. And then over time is the $65 billion, because subsequent presidents have continued with that program coming forward. But the interesting thing is it came from way out to the right, and it came from a people who brought the left and the right together in a bipartisan way. And when I brought it to the floor of the Senate, you know, it was close, but it was bipartisan, and it passed. And when the House passed it. So it will be legacy and legacy changing. And then the spinoffs from it, all that money is spent. It's not just on hiv, aids, on tuberculosis, malaria, infrastructure, structures, surveillance, putting clinics and cities and communities and villages and towns all over the world, not just Africa, but Russia, China, and around the world.

Now, one of the things that put you at a little bit of odds with the party was when you broke with the party's views on stem cell research. Initially your view was in line with the Republican Party, which was to be against stem cell research. You changed that view and in the process, presumably upset people in the party. So I guess I'd start with what changed your mind.

Yeah, you know, it's interesting to sort of go through what stem cell research is, because the changing of the minds or the switching of positions or sort of the role of a senator is one that's kind of worth going through. So I had come to the Senate as a physician. I know brain death well, because all my donor patients, I'm involved in all of those. I am in immunology. When I came to the Senate, I was in and did things like disability policy and health. So people came to me on this particular issue coming in. And there was an amendment back in 1996 which basically banned federal funding of embryonic stem cell research, not adult stem cells. Embryonic stem cells being the ones that were just discovered in 1998. So this is fairly new at the time. And the beauty about those embryonic stem cells, they do something that no other cell had ever done. And that is, you could take it. It could become a liver or a heart or a pancreas. You could kind of channel it in those directions. And the second thing, it was like a. Back in those days, we'd say it's like a copying machine. You can make unlimited copies of it. No other cell ever in the history of man had we discovered. So then you had people who said, these cells are powerful, going back to the heart transplant. Why not take a few of those stem cells, stick it in the heart. Make that heart come alive. The problem is, it had never been done before. And ethically, people didn't know whether it can be done or should be done. But if you had Parkinson's disease, neurodegenerative disease, the hope for everybody, including me as a scientist who kind of lived in this world, was tremendous. So the question was, how do you take these embryonic stem cells and in an ethical construct, allow that research to go forward? And that was always the issue. And do you do it with federal monies or you do it with state monies or local monies? So the issue is all what happens at the federal level. So you have that amendment. And then President Bush came out in 2001, and he said, we're going to fund embryonic stem cells for the first time, but we're only going to do very little. We're going to limit it, because we don't know if these cells are good or bad. That's sort of one line. The more important line at the time was, is it ethical? The embryonic stem cells, the only way you could get them is by creating an embryo and then destroying the embryo. So you can see real quickly where this is going. You got pro life, pro choice, 50, 50 in America, pro life people said that the embryo has the full genetic code. All you got to do is nourish it. It is a human. It may be early on, but it's in the first stage of development. So the ethical issues that where Americans believe that, or half of America believes it has sort of moral value of some sort, do you allow embryo mills to be created? And so that's where the ethical issue a fascinating issue. So Bush said, no, we can't do that. Let's restrict the number of cells. And he said, Here's 78 cell lines because they've already been created, but let's not destroy any more embryos or create and destroy embryos. And so he Limited in 78 lines. So I endorsed that. And about two months before that, this was all written up in the Wall Street Journal because it was all new science and political. I'd written, gone to the floor of the Senate and said, I think that Here are my 10 principles. Let's put them forward and engage federal funding. State funding is okay, and local funding is okay. That's outside. But for federal funding, let's limit it. Like Bush, he limited to 78 cell lines. I said, instead of doing that, let's sort of stay with the times and use these blastocysts or these little embryos that Are used in fertility clinics that are otherwise going to be thrown away.

But they're still pluripotent. These are still completely pluripotent stem cells.

Exactly. You create five of them, you implant a couple, the other three are thrown away. Discard it. So my argument in my 10 principles that I went to the floor in 2000 was that use those. So Bush came out with something different. He limited to 78 cell lines. So I endorsed that because at least we were getting federal funding of stem cells. And then we jumped four years later. And this is what's really interesting to me, and this is really important, I think, for our senators today. Science changes over time. You learn things. There are. There are better techniques, there's evolution of knowledge. Clinical trials prove things. And it got to be four years later that it was clear those 78 cell lines didn't work. They were contaminated by mouse cells. Only about 22 of them ended up being good. And therefore, what was intended to be sort of a limited opening of the door for federal funding, in my mind, had failed because science had demonstrated those cell lines were not sufficient. So I pulled my 10 principles back out again, went back to the floor of the senate, put those 10 principles out there. And the reason it became such a big politicized issue is that president Bush did not agree with me. And the majority of the senate and the majority of the house, we passed in 2005 a bill called, I think it was the stem cell research enhancement act. It passed. It says you can. Could use these blastocysts. An ethical construct was set up. You got consent set up. And then that bill passed overwhelmingly bipartisan, but it was vetoed by president Bush. And so then people said that frist and Bush are in totally different areas. But from the day one, the embryonic stem cells, to me being a heart transplant surgery, were the most exciting science that had come by in 10 years. Years. But when this whole ethical issue came up out of both my own beliefs, when you have nascent life in an embryo and you had these embryo mills being created, Women were being paid $400 to create embryos, to have them destroyed. And there was no mechanism, Discipline, mechanism around that, that we had to create that. And ultimately it got created. And now we jump 10, 15 years later, the same principles that I had put in in 2000 and 2005, the ones out there. And that's where that research has gone. And in retrospect, it's probably been pretty good in the sense that the stem cells eventually are going to live up to the promise. But we're 17 years later, and adult stem cells are used in bone marrow, and cord blood is being used that has no ethical issues around it. It's these embryonic stem cells. And with the research that's out there, it's 17 years later, and some good things are happening. But still, there's no embryonic stem cells being used to treat the Alzheimer's in Parkinson's.

Yeah, I mean, it's such a hard problem. Right. The challenge is, how do you instruct the stem cell? Where is the instruction set that says, I want you to go and replicate 32 times 32 doublings and become cardiac myocytes? And this subset of you are going to go on to develop purkinje fibers, and this set of you will not. I mean, we're still so far from cracking the code of what the instruction set looks like to the stem cell. So this is step one of 10, basically, in terms of that.

But it's hard to tell people that. And as a policymaker, you have to make the decision, you have to set up the construct, or you're not going to fund funding. But you literally have thousands of people who are dying and they had the chronic diseases, and then they have a group of people telling them that within two years, this was all in early 2000s. Within two years, your Parkinson's could be. Or your neurological injuries severing of the spinal cord can be cured with these cells. And therefore, we need to open up the field and forget destruction of embryos or all these moral, moral concepts of life. And that's a tough job of a policymaker. You got 100 regular people there who, some are smart, some are not, that are maybe not perfectly representative of people, but they've got to make these decisions. So it's the sort of thing that at the end of the day, we increased federal funding for stem cells. Constructs were put around it imperfect. His approach was different than mine. People made a big deal about it at the time, but at the end of the day, I think it ended up working out pretty, pretty well and learned a lot. And it comes back to science a lot and these fields that are just so promising. I mentioned synthetic biology, and we think of CRISPR technology today and the creation of kids with blue eyes and brains that are good in math and all of which we could do. But how do you slow that down? How do you bring the discussions not just to the Capitol and not just to the academic centers, but to Main street and get the right ethical constructs? And that's what our policy I'm not a policymaker now in that sense, but that's what these people in Washington do. That's what we hire them to do and that's what we need to hold them accountable. And they need to do it in the best way they can at a point in time. So things are going to shift with time in that particular one. Luckily, I did the same 10 principles in 2000 as I did in 2005 when I passed the bill, it got vetoed, by the way, so I lost. But ultimately, back under President Obama, the same bill was taken out and passed.

What are the restrictions on a president's ability to veto? Can a president veto any amount of majority? Any Senate majority? He can. If 99 senators are in favor of a bill, the president can still veto it.

Well, yeah, it's a good point because if you can have a majority that votes for it or a super majority, but you have to have 2/3 or 3/4 come back. So if he vetoes, you have to take a whole nother vote and then override that veto. So he or she has that intervening time to put pressure on people and change that.

Another very complex issue that you weighed in on, which ties into your past, which is this idea of end of life. Right? I mean, and it's funny, I remember a really complicated case when I was in medical school at Stanford, which involved a patient who was more or less brain dead. But there was a very complicated family dynamic. And I don't remember the exact details, but it was one of those scenarios where every ethicist in the hospital had been in that room to try to talk to that family and resolve the withdrawal of the support. And interestingly, even though this case had nothing to do with cardiac surgery, ultimately the person that came in and mediated it was Bruce Wrights. And it's an interesting story because again, here's Bruce Wrights. At the time he was the chair of cardiac surgery at Stanford. He had by now come back from Hopkins and you know him. So this probably isn't surprising to you, but you don't think of like the chair of cardiac surgery being the warm fuzzy, but he was like the most soft spoken human alive. You would never see him and think that that's the guy who did the first heart lung transplant or anything like that. But it was sort of like, I don't know, he spent two hours with this family and everybody had come to a point of comfort that in the case of that patient, support should be withdrawn. So of course, as a transplant surgeon, you are intimately familiar with what the criteria are for brain death, what makes a donor, what does not make a donor, et cetera. And so again, here you are now, Senate Majority Leader, and a very public case comes up, this case of this young woman, Terri Schiavo. And I guess just for folks who don't remember this, and you can correct me on some of the details, but my recollection, because I was in residency, this was such a big discussion for us. This is a young, healthy woman who, I guess, unbeknownst to a lot of people, had an eating disorder. So she had bulimia and through lots of repetitive purging, had developed profound hypokalemia. So very low potassium. So she's otherwise looks perfectly healthy on the outside. But I believe her potassium got as low as 2 to 2.5 milliequivalents, which, not surprisingly, put her into an immediate cardiac arrhythmia and arrest by the time the paramedics arrive and resuscitate her, because she's so young and healthy, they can get her heart beating again, but her brain has been without oxygen for minutes. No one really knows. This was in 1990, if my memory serves me correctly. Fast forward a few years now. Her husband, Michael, and her parents, whose names I don't remember, are basically having a different point of view about what to do. And the husband believes she's going to be in a persistent vegetative state for the rest of her life. This is not what her wishes were. She's being fed through a tube. The parents feel otherwise, and it just keeps escalating its way through courts, and it gets higher and higher and higher and higher. I don't remember exactly how it got to the point where Congress was now being asked to weigh in, but maybe you can pick up the story of how this basically rose to a national story and frankly, even potentially involved the U.S. congress.

Yeah, it is a fascinating story, and this is one again. And, Peter, I haven't talked about a lot, in part because it is complicated and you do need sort of the time, and we can do it very quickly.

Oh, no, no, we don't have to do it quickly. Yeah, yeah, yeah.

No, but, no, it is a fascinating case, and because it has implications for everybody listening to us today. Everybody. And it will have even greater implications in the future as technology can do these miraculous things here. It was miraculous in the sense that it could even be kept alive on a ventilator for a long period of time. But increasingly, it's going to get more complex because technology and science is going to Give us these tools to use. So lots of lessons. And so it is worth going through it. So you're exactly right. 1990, Terri Schiavo collapsed. Hypokalemia for just a persistent vegetative state is a medical term. It's an important term here because the law uses it. But for people who are listening to us, you know, you're on a ventilator and you can move and open your eyes, but it's just you have to be supported overall with both feeding tube as well as a ventilator. And Michael, her husband, you know, did everything, at least in my review at the time. He took her to ucla, took her to multiple centers and for rehabilitation. And then three years later, in 1993, he'd given up, basically. And I don't know, I wasn't involved with the family then. This is 10 years later that I got involved. But the issue was exactly as you described, that all of Terry's blood relatives, the mother, the father, the brother, the sister, objected to Michael putting her on a DNR or removing the tube. Do not resuscitate. Removing the tube. So you had this dichotomy of walking the room, just like you said Bruce did. You had on one side, one person who by the law says if she's in a persistent vegetative state, the husband can make the decision. On the other side of the room, you had all the mother and father who raised her, who cared for her, her brother, her sister who said, no, she's responding to us. She's alive. Touch her, feel her looking, her eyes. She recognizes us. And so the parents and Michael disagreed on their impression. They also disagreed because she had. And this is what the implication is. Everybody listen to sort of this part. She had nothing written down. She had no living will, no advance directive. And therefore, you had the parents. And everybody says, well, of course, she's a devout Catholic. She values life. And you had the four of them saying, you know, we'll support her. We'll take care of her financially. We'll take care of it. And then you had Michael, who by the law would have that responsibility of saying DNR or not.

I just want to interject there for a second. I think it's such an important point you made. And I had actually scribbled notes down to bring it up. So I'm glad you did. I don't think you or I, as doctors could overstate the importance. Importance of an advance directive enough. And I think a lot of these issues could be resolved if while you don't have to worry about it. You go through this exercise. I mean, my wife and I did this 12 years ago, sat there in a lawyer's office and spent an hour going through what we wanted and what we didn't want, down to the levels of detail that is comical right now. Not everybody has the luxury. They might not have the medical. My wife's a nurse, so, you know, we could talk about it through. Well, this is. I would tolerate this many line changes at this many weeks of a trach and this feeding tube, blah, blah, blah, blah, blah. But it is very important, I think, to do this, and hospitals are getting better at it. Now for people admitted electively to at least have a box that you check that says, do you have an advanced directive? But I think everybody should have one of these things, because the time to build the roof is when the sun is shining. And the time to have this discussion is when clear heads prevail.

And it's hard. You just have to do it. People don't like to think about death or where they're going to be buried or wills. This is one that. Out of respect for your loved ones. And it plays out here. And I'll mention it again, because I'll come back to it, because it had real implications, but they had nothing. The interpretation of one set of relatives. And then the husband were very different. So jump ahead to seven years. Her feeding tube was taken out. Then a court. These cords, as you said, kind of came in and they replaced it at the time. Then 33 medical specialties. And this is why I had to go back and review all this. Eventually came forward and had affidavits that her condition was not beyond some sense of recovery, that she could improve. And so seeing that complicates things a little bit because she's in this either minimally conscious state or persistent vegetative state. So in 2003, the court ordered five doctors. These are state courts, ordered five doctors to test Terry, two appointed by Michael, the husband, and two appointed by the family, and then one appointed by the judge, three to two. They said she was in a persistent vegetative state that would be okay to withdraw therapy, take the tube out, take her off the. The ventilator. The two who voted against that said, no, she's in a minimally conscious state and can recover. So she stayed alive for about six days. And during this six days, it became this huge global issue. It went to the state of Florida, the state, the equivalent of their House and Senate. The legislators got together and actually passed a law in that Six day period that gave Governor, Governor Bush at that time the order to put the feeding tube back in. All this is over a six day period. The Supreme Court there struck that down. Again, this is kind of the politics. And you say, oh, gosh, as you said, the Bruce writes of the world, these sorts of decisions as a physician, and I'm talking about one who's run disability policy for America, who's been in brain death, who's been in the whole field of transplant, whose whole career has been around life or death. These decisions should best be made by a family with a directive, with a physician or a caregiver, maybe with a faith person in that room. But this got elevated throughout the politics you had. Pope John Paul made a statement on behalf of the family and the sanctity of life and that they would support her. And that was their belief. The brother, the sister, the parents had keep her alive and that they would support it financially. And somebody gave $2 million or said they would give $2 million to support her. So that's it. So of course, coming back, being the only doctor in the Senate, and maybe it was one more at the time, and knowing brain death, I was involved in all those discussions and when I was at Stanford, the ethical issues, the disability policy, the only physician. So I jumped, didn't want to do it because I don't think it should be done. It should be really rare, really exceptional. But this had become a global issue on the news every night. And again, it was a long time ago at this point, 2003. So I asked myself at that point, does the government have the right to terminate life when the family objects to it, if they'll financially take it? And that was kind of where I came down to. And the question is, which part of the family do you listen to? The one that the law would give it to. Ultimately, ultimately it would be the husband or all of the siblings and the loved ones and the people who had lived with her and taken care of her in large part. And it's a little bit like coming back to the transplant world. If I walked into a room to remove a donor heart, to bring it back to Vanderbilt to transplant it. And I walked in the room and the patient was there in the operating room and there was a spouse who said, no. He said, take the heart, it's okay. But the rest of the, the family said, no, we don't want you to desecrate the body of our loved ones and take the heart. Even though the law would say I could do it under these Donor laws that we have. I wouldn't do it. Of course I wouldn't do it. To me, it's just not the right thing to do. So what did I do?

Have you ever been in a situation like that, by the way, where the legal spouse, the person with the legal right to authorize the transplant, says yes and a group of others say no?

It's fairly fair, as you can imagine. It's fairly. It's rare, but it's common. And so, no, I did not. I would not take off in the airplane tonight if I knew, talking to the donor counselors up there, that the family disagreed, although legally. So I avoided it totally. And others may have done it, but I would not do it. But, yes, it's not that. You know, as you can imagine, you get six members of a family and they all disagree about something. Something. Unless you have a Bruce Wright's walk out. You've described that well. So the first thing. I'll go faster. The first thing I did is I called the last neurologist to examine her and he said she's not in a persistent vegetative state. It's a mentally conscious state.

What is the difference there? I mean, I want to just kind of make sure some people understand what we're talking about. She has some brainstem function. For example, if you touched her cornea, she'd blink. Presumably if you injected ice water in her ears, you'd get a doll's eye reflex. Did she have a gag reflex?

She had a minimal gag reflex, which, you know, so she had. The definition is not by a single test. So it is a clinical test. And there are certain tests that you just ran through three of them. There are certain tests that you do, but things like an MRI and PET scan, she hadn't had any of that. She ultimately had them after she died. And she did have very, very serious disease. But it's a tough diagnosis and that's the world we live in.

Oh. So that CT scan that we of her head that shows basically it's mostly fluid, there's no brain matter. That was postmortem.

Yeah. After. See, that was after six months later, because then it all surged up again, as you can imagine. So talked to the neurologist. He just happened to be the last neurologist. I personally, as majority met with the brother. He was clearly going to be coming to us. The house had already sort of called for the case. I talked to the family and the family said, don't terminate her. I looked at the medical records again, just because I Was curious about it. And it was clear that she had not had an mri, had not had a CT scan, had not done any of the current things. Remember this happened back in 1990. So I checked what I did. It was there now. And so I checked with the Senate leadership. Harry Reid was a Democrat at the time. Became bipartisan. The House led on a bill. I'll come back to what the bill was. And we had a bill, and it was bipartisan, supported unanimously in the United States Senate, overwhelming majority, both parties in the House of representatives and 15 neurologists had signed an affidavit and all of that that said that she needed an independent current evaluation, that she hadn't been evaluated recently. So really controversial. Even among my staff, they said, what in the world are we doing? And I said, I know, but this has come to us and it's. And it's at an issue that cannot be resolved. And I said it should be rare. It should be decided locally, the way for 20 years in medicine that I'd been able to decide life and death decisions, which I was in this field that you do. Bill passed unanimously in the Senate. In the House, I think it was like 210 to 50 something bipartisan. What it did. The bill itself guaranteed a process and not an outcome. And so it basically didn't say keep her alive. It basically said she needs an exam that is truly independent, not with courts, and not done by politicians. And once that exam is done, if she's in a persistent vegetative state, then remove the tube if that's what the husband wanted. And if not, the family should be listened to, the extended family should be listened to. So the outcome, it passed the United States Senate, it went to the federal courts, they denied the petition, and the feeding tube was removed and she was allowed to die. So that's the story. So it's an interesting one. And on reflection, again, publicly, I don't go through this, and I've written some about it because I've written a lot about brain death issues and persistent vegetative state. But as a policymaker, the story captures this sometimes necessary conflict and this very real tension between the rule of law and the law basically said, well, the husband can decide. And this broader consideration of ethics and morality and in this world of increasing technology and the ambiguity of not having any sort of thing written down. So in retrospect, people ask me, because a lot of people say that's got to be the biggest mistake you did in 12 years. And I say I kind of just avoid it. And Move on. But in retrospect, the fact that it didn't come, I'd probably do the same thing and pass the same bill. Set up a process and not an outcome. And I was the only person in the Senate at the time who had taken two oaths. And one of those oaths was to the Constitution, the life, liberty, pursuit of happiness, the oath that all those 62 lawyers and everybody taking the Senate, but had also taken this other oath, this Hippocratic oath, to protect life and to do no harm. And when there's ambivalence around that and when the family wishes otherwise, and it's true ambivalence, I will opt on life and I will opt on what I would interpret as life. Others may not. And this has got to be exceptional and rare. And it has been in retrospect. And those kind of cases have, haven't made it back to Congress. And these decisions clearly, clearly, clearly are best made locally. The other challenge I'll close on that is the politics made it worse because you had the Chris Matthews of the world who would go out every night and, you know, big sort of Democrat and sort of after people, and he would basically say, here you have Senator Prist playing doctor in the United States Senate. You know, he one of those other Republicans. And then the Republicans would shoot back from the House and say, oh, this is a great case because it shows right to life. What I did and what I tried to do with these, and it's hard to do, is to separate the politics from the policy, to separate the politics from the science. And it shows. This case shows that this inherent tension and challenge to our policy makers, who are, whether it's at the state level or local level or federal level, are given our trust to make decisions like this and to have appropriate oversight. The decision should be locally, though, as much as possible.

Yeah, I mean, I definitely agree with that. My personal views notwithstanding on this case, which is that I think that I can't understand how a CT scan wasn't done in the late 90s, frankly, to have made it to so obvious as to what the state of her brain was. I think the interesting point here is that you were probably the least political in my view in that because that's the advantage of being in your final term in a Senate when you've publicly declared you'll never run for another office is you don't technically have a political dog in the fight anyway. So even though your viewpoint was viewed as political, I think it was. Those were your personal views and people are free to disagree with them or agree with them. But I didn't think of it as necessarily a party view because I don't think there was anybody in the US Senate that had less of a stake in what the party felt. That was just sort of you were voting your conscience. And we may disagree with that, but I don't think it was political.

Yeah. And you know, issues, all issues. And even with impeachment back in the past, people have a hard time on understanding that politics is a part of our democracy. And you wish. And with things so partisan, everybody wish. Not everybody, but so many of us wish you could push this extreme partisanship out of it. But even things like impeachment, there's a political nature to it. It was intended to have this political thing. And politics and policy can't be separated totally. And that's why I come back to this tension that has to be there, this discernment and this past experience and not arguing the law to the extreme, that you can't see a larger picture because laws are imperfect as well. And that's the sort of representatives that I think we need to aspire to and then elect and have people get involved enough in politics that they can elect those sorts of people to these bodies of Congress, the Senate or governors or state assemblies. Please.

It's so hard to believe that we are now in the 20th year since 9 11. I want to go back to that Tuesday morning for you because I think anyone can remember, anyone of a certain age can remember every detail of it. But I can't imagine what it's like to have been a member of the United States government at the time, let alone a senator. What do you remember about that morning and what was running through your mind as this thing was unfolding?

I still have nightmares about it. We all have the anxiety like we feel with COVID and other things, but the nightmarish experience of having an assault that we have no idea how big it is, how deadly it can be, coupled with being in a position of having to make decisions at that point in time. He was United States Senator. The security at that time rest 100% with the President and a co equal branch of government, the Congress, and with inadequate information, no information having to make decisions there. So the fright of it. My first thoughts when it hit, I was out in front of the Capitol and over at another senator's office and the first plane hit. And I fly and fly a lot. And it'd be really unusual for somebody to hit a building World Trade center, but it could be done or it could be a suicide mission.

You even thought that during the first. Because when the first plane hit, I remember I was in the trauma bay at Hopkins and I remember someone coming in and saying it. And I had just assumed it was like a Cessna had hit on a foggy day. Did you know that it was an actual passenger plane?

No, not at first. I was in an adjacent room. I was outside of the Capitol in an adjacent room. And somebody just said, should you stop your meeting because the plane hit the Capitol? Same thing as what you said then when we figured out that it was an airliner. And then shortly thereafter, the second one hit. I was in leadership at the time. I was in the top five of leadership at that time doing the Senatorial Committee. So at that level you get briefings beyond what other senators get. And then when you're majority leader, you give different higher level briefings. So I knew that a lot was going on in the world and that there was a lot of noise on the Internet, but nothing that you'd think about. But I knew the capacity, that this wasn't just like a small thing. This was really going to reflect the world. And then when there were two, always when there are two in life, there's going to be a third in these sorts of things. And so that was it. So my first thoughts were that the second was. And at the same time, and probably really first were my kids, because my kids were in school over in Washington, over near where the Vice President lives and it's near the cathedral. And I knew if they're going after us, they're going after the Pentagon, they're going to hit any sort of symbolic sites and that they went to school right there. So of course concerned and worried about them. And. And then that was it. Then there was this long period of time where we got together and were shepherded to an off site secure location. And people. There are certain people in leadership that are identified. So if there is an atomic bomb or if something happens, we can refashion government so those people are taken to a secure location. A few senators, a few House members, a few Supreme Court justices, President or the Vice President. And I was not part of that particular group. But it was at that level and it was as intense as anything in surgery that had gone awry that I'd ever done. There wasn't panic there. But this world of not having any information, no intelligence, essentially no intelligence, and not knowing where it's coming from and not knowing what was going to ensue over the next 12 hours. It's different than anything at the operating room, at the table. And there you're doing life and death things every day. This was different.

Do you recall what you went through over the next two or three days? Because I think back to it and I've been thinking a lot about, as we approach the 20 year anniversary, the stuff I want to talk about with my daughter who obviously was born after. And in some ways it feels like it was yesterday because there are things about 9, 11 I remember as though they literally happened a week ago. I remember exactly where I stood. I remember exactly what the TV looked like. I remember moments that evening because none of us left the hospital for two days. You still were in a state of, are there going to be people coming here? Do we need to be here? And then there are other things that are a total blur. So I can only imagine in your situation that's amplified 100x. But do you also have sort of pockets of that period of time that are almost a blur, or does everything still sort of fit nice and neatly and linearly into your recollection of the weeks that unfolded from that?

Yeah, no, it's an interesting question. I think the difference was that we knew we had to act and the first thing that we needed to do quickly, we didn't know if this was a single actor or a single state, a single group, a country, multiple countries. And we didn't have the intelligence. And so once we found out we didn't have the intelligence, which was pretty quick, we had to pretty much assume that we were going to all be taken out. And by us, it's not us, we don't matter, but it's the United States of America. So you go after New York, you go after Washington D.C. you destroy the Congress, you find the President. So ours was how in the first six hours, eight hours actually, that night, how we could display to the world that this is terrible and unprecedented and has to be addressed. And so we said, how do you do that? So we all stayed at the Capitol, we went to the front steps of the Capitol. And this is the sort of thing that does bring Democrat and Republicans together. I mean really closely together, and nothing else sort of matters. We're talking about the safety and security of our country and maybe existentially, the future of our country. And so we went out and I remember obviously the people you think who are there, the leadership was there, of course, and the people were there. But the John Lewis of the world spoke and we displayed to the world that you can try to take us out, but you can't take us out. And I think that was really important. We did that after the anthrax attacks, other attacks, we sort of did that. But I think it's really important to make that statement to the world, to stand strong. And then it was once we knew we could reconstitute government if something worse happened, it really was just sort of systematic, of up and run. This is how much intelligence we have, making decisions, should we hit, how fast we should hit, should we hit it all coming back, if we hit what's going to come at us next. So it was a busy time. And then I had family. As I said, that was always in the back of my mind. Just being in Washington, D.C. one of.

The things that you said that really stands out to me is the amazing lack of partisanship that existed for a brief window of time following the attacks of 9, 11. And obviously you could say, well, it was an external attack directed directly at the United States. But does it surprise you that a pandemic like Covid didn't have any of that effect of unifying the country? There was. I can't, at least politically, it doesn't seem to have done anything to have unified people. It's driven people further apart, and yet it's an enormous existential crisis. Do you think this is different because a pandemic is not enormous nation state and it doesn't affect the US Exclusively?

I think when you can externalize your enemy or the assailant in some way brings people together, you got an image, you can create an image. They're out there. There's somebody. There's an embodiment of something that is external to you, that you can project towards and receive sort of incoming on. When you have the virus itself, you don't have that because the virus is this cagey little thing that knows no borders, that is truly global, that does not discriminate at all. And there's no sort of externalization of it. There's no sort of sort of setting it up and putting it on the table and saying, let's do it. I think the other big thing, and there's no reason to get into the politics of it, I think the leadership was different as well in our government. The communication was very different. And that to me, has been the most disappointing. When I look at the big assaults on our country that were on our soil here, whether it was anthrax, with 14 or 15 people dying here and hit our Capitol, whether it is 9, 11 and now the pandemic, my biggest disappointment has been the lack or maybe just the difference in the type of leadership that was demonstrated. It's leadership, communication, how things are articulated and the like. And I think that plays a big role. I think that if there had been a. A call to action with appropriate communication, leadership, trust, empathy, understanding that this pandemic could have been externalized and we would probably have more rallying around it instead of this, what you see on social media and Internet and television, which continues to this day.

In 2005, you quite accurately predicted what we're seeing now. You referenced the 1918 Spanish flu, and you said it was not a question of if, but rather a question of when we would experience another pandemic, another virus. Specifically, you very astutely pointed out that these 10 things are basically going to happen. There's going to be complete total social chaos. There's going to be supply chain disruption, boom, boom, boom, boom, boom. And a pandemic preparedness strategy should include stockpiles of antiviral medications, all of these other things. It's easy to blame one party or the other. But the reality of it is no administration's really ever taken that seriously, have they?

People have taken it seriously. I'd say both administrations have. And this may come back to where we started, that my experience coming in was colored BY Things like HIV, AIDS, killing 3 million people a year, was characterized by anthrax, which, when it hit the Capitol and knowing the potential of what it could do, the lack of preparedness was just crystal clear to me, just based on my past experience. And so what I did in 2005 is you said 20 different speeches I gave all basically off the same speech, but I gave them on the East Coast, West Coast, Silicon Valley, the floor of the United States Senate, far reaches like Nantucket, the Red Forest of California, everywhere. It was essentially the same speech, as you said, it was called the Manhattan Project. It did predict it was going to come because of this admixture of birds and animals and transportation around the world. So it's clear. It's clear from a medical standpoint.

And just to be clear, you thought it was inevitable just from these factors, not necessarily even bioterrorism. I mean, you were thinking that would be another potential way, but it was.

Yeah, okay, yeah. And I use the bioterrorism a little bit because I talk about that as well. Because you could intentionally manufacture any of this. You hook it onto a virus or hook it onto smallpox, where you have something that's real transmissible and it's not that hard to do it's. Real easy to do. You can do it in a room, 8 by 12 foot room with simple things. And so the bioterrorism at the time, because of 9, 11 and all the things that had gone on, it was clear we needed to worry about that, especially with smallpox, because Russia had a supply of smallpox they could use. But no, this was outside of that. This was sort of coupled with that. Because the same things that you need are the communications, the infrastructure, the stockpiling, the virology, the research and development, the antiviral agents, the manufacturing capacity, all the things. These are all the things that, as I say them now, people are saying, oh, yeah, check, check, check. That's with COVID And the point is, and I called it a Manhattan Project in each of these speeches. And as I said on the floor of the United States Senate, I left the Senate the next year and work has been done and people have tried to do pieces of it, but nobody has really stayed on it. But the six proposals. I testified before Lamar Alexander's committee about the next pandemic about three months ago, because right now is the time we have to talk about the next pandemic. There will be another pandemic and will we be prepared? And we all know, and especially political people, that, you know, it's only the snake that's at your foot that you're scared of. Once the snake goes off in the trees, you just lose that sense of sort of urgency. There's so from the scientific standpoint, I mean, I wasn't any great. I mean, we say this like I could see it. I wrote it down and I wrote what we should do and what we should do, we didn't do. And therefore it's interesting to go back. My biggest fear is that you write that same talk and you give that same talk or somebody does, and there's nothing done after that. And I don't think that'd be the case. But it's going to take, you know, a constituent and people saying this is an existential threat. This Covid thing is not a deadly virus. I say that.

I mean, that's my fear, right? Is we kind of. And you say this and it sounds horrible, but we dodged a bullet here. This virus is quite a wimpy virus relative to the Spanish flu or the Hong Kong Flu or SARS1 or MERS. And there's a sweet spot, obviously, if a virus is so deadly that it basically knocks transm. Like if it's an Ebola virus, in many ways those are less threatening because they kill People so quickly, but there's an inverted U shape of lethality. And SARS COV2 is actually quite far to one side, which is. It's so non lethal that it's so contagious. But you, you take its lethality up one order of magnitude, it still wouldn't, especially if it has a long latency. It's a devastating virus. I mean, it kills tens of millions of people. And I think you're absolutely right about the snake at your feet. Like, there is a certain amount of political capital that probably exists now in 2021 to really say, okay, well, how much money is the government willing to spend to make sure that the next time this happens, we're not on our heels.

Yeah, exactly. And it's funny, with Lamar's committee, he ran the health committee, was chair of it, the health committee, and he took a lot of heat. I listened to it. I love not being there because I can sit there and listen to the hearing and give my testimony. But half the people would say, lamar, this is crazy. Looking for the next pandemic, seeing what we should do. We've got a pandemic now. And he said, well, you know, of course we do, and we're doing everything we can, but look what history has led us to. And you know, there are clearly things to do, but how you get people to stay on it and understand. And there's simple things. Infrastructure right now, things like vaccine distribution, which has been so challenging. And that's the sort of thing in public health infrastructure. Locally, there are fewer public health people on full time payroll in our communities today, wherever you are right now, than there were eight years ago. Public health people. Public health has been the stepchild of health and welfare and healing. That is inverted now and people appreciate it, but we can actually deliver on it. It not just next year and not just put more funding in it, but really do it over a period of time. And that's the challenge. And again, why getting people to these bodies and opening those bodies up to whether it's more scientists, more thoughtful people, people getting other experiences from life and having them participate and supporting them in those positions.

So I want to kind of go back to just this broader topic of the political world we live in today versus the political world you entered and left, which is in some ways not that long ago, but yet seems like an awful long time ago, frankly, if you think about the historical arc of politics, which I frequently try to do, and think back to the worst of times, and maybe this isn't so bad, but help Me understand you gauge your level of optimism for me in terms of, of this infrastructure, right, which is the two party system, the systems that are in place that have rewarded the extremes and punished the compromisers, the tools that amplify it, social media, cable news, all these other things that everybody can rattle off, all the things that could be broken today. How optimistic are you that if we can both agree that where things are today is suboptimal optimal, it's going to get better?

Yeah. You know, on my podcast I ask people sort of the optimism question a lot and 90 out of 100 say they're optimistic about things. That's really interesting. And so I'm slowly going to answer it because I think you have to be really, really careful. First of all, I am optimistic and again, it's my nature and I tend to get involved in things that seem to be challenging and I love just working with them and bringing people in and things tend to work out pretty well. So I feel good about it. I think the next few years are going to be really difficult and probably not get a lot better and may get worse. I think if you look at structures that are contributing to it, we're going to figure it out. And I don't blame social media, but it's an accelerant. And the way we are going to figure out in some way to curate social media in a way that still allows freedom of expression and free speech, but where it can't be used in the negative ways, whether it's in partisanship or misinformation, I feel good about that. And part of it's in discussions with people in the sort of Facebook direct world and the Amazon world and the Google world and the Netflix world. It's going to take a little bit further, but I think we're going to get better there. When we get better, that will put us in much better standing because we're still on the curve of getting worse. And it may get worse in this world. Populism, it may get a little bit worse, but it will get better and I'm optimistic about that. Leadership, I think is going to take a while. I'll tell you just a real quick story. When I was in the Senate, things are partisan again. We don't want to idealize the past, but President Bush and President Clinton did not do this as much. But President Bush came in and we were in sort of this, you know, 9, 11 sort of world, but came in and every other Friday would take three people from the Senate leadership or four, two Republicans, two Democrats. And from the House leadership and every Friday, do breakfast with them quietly, no press, right off the Oval Office. And it was uncomfortable. You'd have the. I shouldn't mention any of the names, but you'd have the people who are the leaders around the table and, you know, people like Nancy Pelosi and President Bush sitting side by side for breakfast for an hour. There's a little bit of attention there. But I. And this was before the Iraq war, and things got really complicated in so many ways, but for that period of time, things seemed to be so much better, really uncomfortable. And people, I don't know if people have talked about that either, but I say that and preface that because I do think, think if you have a president of the United States, President Obama didn't do it and President Trump didn't do it, President Biden, it looks like he would do something like that, but you just don't know. But I do think if you had, at that level, not at the level of Chuck schumer and Mitch McConnell, it was too ingrained there, but at that level, you pulled people together and said, I'm willing to lose my next election as president of the United States and again, take President Biden or President Elect, soon to be President Biden, out of it. If you had somebody like that who stayed with it, it would make a difference. It gives cover for people below. It gives cover for the majority leader and a minority leader and the speaker and the Democratic leaders in the House. And that's not that hard. I mean, that kind of makes it sound simple to do. But. But sort of my experience and my thoughts, it could be as easy as that to begin to turn the tide. And I think we'll see that. I don't know if it'll be the short term or long term or how long people will be around, but it takes that sort of courage to do it, to say I'm willing to sacrifice a second term or something like that.

That's a big sacrifice, though, isn't it? I mean, that's not something to take lightly.

Yeah, it is. But it's gotten to the point that how you elect somebody who really will do that from a very partisan group makes it hard, but it's doable. And we're talking about regular people and people who can be reasonable and not always, it depends on the individual. But for those two reasons, I'm optimistic, because I think it can be done. I think it probably will be done, and it can be done pretty quickly. I think there's a real call from People for this sort of bringing people together doesn't mean sacrifice your principles. It doesn't mean sacrifice your party. It just means come to the table and be able to have a discussion and have a disagreement and leave, as we did, sort of more in my first term than in my second term in the Senate. Sort of shaking hands after you have a big debate on the floor of the Senate.

You know, there's so many other things I wanted to chat about, and we're really, we've gone a lot longer than I thought we would to this chapter, but we really have only covered a couple of the chapters of your life. There's an entire chapter that follows what you did in the Senate, which is in some ways the busiest chapter of your life in the last 15 years. I guess, just for the sake of brevity, what has been the most interesting project you've worked on? Because you're doing venture capital, you're on the board of For Profits, not for Profits. You're a part of the Bipartisan Policy center, which is an organization I'm quite familiar with and quite impressed with. I mean, your commitments span so much. What has been the most interesting and I guess what have you brought from the two previous chapters to it?

Yeah, that's a great question. Because people, it's a little bit like they look at you, probably, if you look at your past, you know, you've done different things and you've tried different things. And is there any sort of narrative or thematic that sort of goes through that? And for me, it goes back, I'm sure, to this whole image of healing and health and hope and all. It sounds a little bit gimmicky and all, but it does come back to that in my mind. Learning to be a doctor, sort of practicing the transplant world. That was 10 years learning and 10 years delivering. And then 10 years and 12 years in politics and then 10 years in sort of the private equity world, and then the last five years in venture capital. All of it's around health and healing, everything I do, everything. And so what I did when I left the Senate, I said, now what is the next step? I smartly said, 12 years in the Senate. So I said, putting together my past experiences, what if there's one thing that could be done to change the course of history? This is thinking big. And it's not the sort of thing you tell anybody at the time, what would it be? And based on 20 trips to Africa and the global experience and all, and hiv, AIDS globally, and I came back to one thing and it was K12 education and globally probably K12 education for girls. And if you're going to spend a increment of time with my experiences, where would it be? So what I did is started a foundation. It's called State Collaborative on Reform of Education. It's by far the biggest in the state. Now I started it, but got really smart people and good people, dedicated people to run it. And, and with that it has had an impact where Tennessee has for the last 10 years shown dramatic, dramatic improvement in K12 education and been recognized as such. So that is a little bit out of health care. But the nexus between health and education is so real. The health feeding into being better educated, the more educated, sort of the better health, it just feeds together and I see it and the data is good. So that's sort of the one big bucket that I made a conscious decision. If you look in the investing world, what I do is focus on mission directed health service companies, not pharmaceutical companies, not molecules, not devices, not all of that. And so I start around companies, I start companies and support companies that have a mission of taking people, usually vulnerable populations, and lifting them up. And the one that I'll just mention, because you asked for one, is one that kind of comes back to the things we've talked about is palliative health care. In our country today, most people do not die the way they would want to die. Hospice, the last seven days, four days, three days is really good. In America, finally, after 50 years is really good. But in this world of chronic disease where people are living and as you described so well in your talks, you push that down slope on the chronic disease and the aging out as far as you can. But at some point you come to those graphs that you draw and you're going to bring things to a close and it's chronic disease. So think of it at that last year of life, that last eight months of life and it's called palliative health care. In hospitals, traditionally, if you're at Vanderbilt or Stanford or Mass General or your local hospital of people listening, today you can get good palliative health care. But if you live 30 miles away or 50 miles away or 100 miles away, you can't and you're sitting there with a chronic disease, you're going downhill. Your family, if you have family local that don't know what to do, do. And so what we did is create from scratch a company that focused and is now the largest palliative, non hospice related palliative health in communities in the country. And it Started with this full circle sort of thing. It started with when I mentioned that I had hundreds of people being referred to me back in those early transplant years right over here at Vanderbilt. They were coming in, but I could only transplant one every four or five days. I didn't have enough donor hearts. So I had 50 or 60 people coming in who were going to die within six months, flying in, coming in, saying, we need a transplant. And I said, I don't have enough donor hearts. And so I had to learn how to take care of them, prolong their life and getting the stuff right, the nutrition, right, the exercise, right. The mental health, the spiritual health, right. All of a sudden they started living not just six months. They wouldn't come here if the doctor hadn't told them it was going to be six months. But they lived eight months, nine months, 12 months. So seeing that, and then I lost my mind and went to the Senate, and then I got out of the Senate and I came back and we're still in the same place. Nobody had developed a palliative health care system for the last year, eight months of life that looked at the spiritual, that looked at the mental, that looked at the nutrition, nutritional, that looked at the exercise and sort of general acute care, medical care as well. And so that's sort of a good example of the sort of companies that I believe in. It ties things together. There are needs that are out there, and there are lots of other areas like that out there. The area of the frail elderly today who don't need palliative care is doing another company right now, just a year old, because they've got social determinant, $35,000 of that cost plus $35,000 of medical cost. But nobody's put all that together to treat them holistically. So those are the sort of examples that are exciting to me, that are really no different than the innovation of the new ideas and the execution, which is most important of doing a heart transplant and figuring out how to some way figuring out that cardiac biopsy to determine inflammation, and then developing a new drug like cyclosporine, which revolutionizes that field. It's doing it in the business world where you have access to capital, you can move fast, you're not slowed down by government. So it's pretty exciting.

Bill, if ever there was a renaissance man, you are that man. And I still think in many ways, I know you don't agree with the idea of term limits, and maybe that's not the answer, but there really is something to be said for having people in the government who haven't spent their entire lives in government. And I don't know, I think the trajectory of your career is very interesting, and maybe we'd all be better served if you were still in government. Although I don't know that you'd still want to be in government. I can tell by the look on your face you're probably glad you're not.

Just fine.

No. It's been a pleasure speaking with you today, and I thanks for all your service.

Great. It's really a tremendous honor to be with you. And the stories we talked about I really haven't told and discussed, but because of my huge respect for the nature of your podcast, it's a real honor to be with you. Thank you.

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