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

Episode Date: February 22, 2021

Bill Frist is a nationally acclaimed heart and lung transplant surgeon, former U.S. Senate Majority Leader, and is actively engaged in health policy and education reform. In this episode, Bill takes us through his long and varied career in medicine, politics, and business, which includes establishing the organ transplantation program at Vanderbilt as well as rising from the lowest-ranked member of the U.S. Senate to the Majority Leader in two terms. We discuss some of the most significant moments of his time in the Senate, such as advocating for AIDS prevention programs' funding and addressing complicated issues like stem cell research and the end-of-life issues raised by the Terri Schiavo case. We also hear his first-person account of what happened behind the scenes on September 11, 2001, his frustration with our lack of preparation for the pandemic, and his thoughts about the current state of U.S. politics. Finally, we talk about his current endeavors in health policy and education reform. We discuss: Bill’s decision to pursue medicine and do organ transplants (3:40); The miraculous nature of organ transplants: History, Bill’s work, and the most exciting things to come (12:00); Frist’s experience building up the heart transplant program at Vanderbilt (21:45); The famous rivalry between surgeons Denton Cooley and Michael DeBakey (29:15); How the medical field can attract bright young people to pursue medicine (33:00); Bill’s decision to leave medicine and run for the US senate (38:00); The value in having scientists and physicians in Congress (47:30); A discussion on whether or not senators should have term limits (55:30); The highly polarized nature of politics, and how we can fix it with empathy (1:00:30); Bill’s time in the Senate and quick rise to Senate Majority Leader (1:05:30); The lifesaving impact of the President's Emergency Plan for AIDS Relief (PEPFAR) under George W. Bush (1:15:15); How Bill reversed course on his view of the value and morality of stem cell research (1:19:45); Complex end-of-life decisions, and Bill’s role in the infamous Terri Schiavo case—a story that captures the conflict among law, morality, and improving technology (1:30:00); Remembering the events of September 11th from Bill’s perspective in the Senate (1:49:45); The coronavirus pandemic: Bill’s accurate 2005 prediction, and a discussion about future preparedness (1:56:45); The divided state of US politics, and how we can come together (2:06:45); How experience in medicine and politics is shaping Bill’s current endeavors in business, reforming education, palliative care, and more (2:12:45); and More. Learn more: https://peterattiamd.com/   Show notes page for this episode: https://peterattiamd.com/BillFrist    Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/   Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/   Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Atia. This podcast, my website, and my weekly newsletter, I'll focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in depth content if you want to take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you want to learn

more now, head over to peteratia MD dot com forward slash subscribe. Now without further delay, here's today's episode. I guess 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 a 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 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, then you can count on, probably spend 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 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, you know, 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.

We talk a little bit about his optimism as to how things might get better in the future. 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 talked 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, the most common thing I get, do you get called Senator or doctor? You know, people's two things come to mind. Number one, the most common thing I get, do you get called

Senator or doctor, you know people who want to be formal and of course I say call me Bill But but that is a harder one because in the Senate, you know, especially today people that cut it down on The the respect world and doctor is still pretty much up there. So you know, I say well doctor But you're supposed to call a senator, etc They'll pretty much up there. So, you know, I say, well, doctor, but you're supposed to call a senator, et cetera, et cetera. 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 the sort of the southern way of doing it. And I remember going down and 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, he's got like the mister. And then he turned around and said, don't you ever, ever say, sir to me again. Yeah, funny.

It says, it depends on where you are. You're exactly right. 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 fortune at circumstance and then I was last to 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 on the cardiac surgery. So he was in this track. And so I pretty much have seen him. I would go into medicine 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. And so 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 not a premed. 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 then, medicine? You know, in high school and in the 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 band, or 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 tract at Princeton, but still wanting to go to medical school, you know, even the school's 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 tracked things in those college years. And so what was it like for you, you know, mass general, obviously, is one of the pillars

of American medicine. 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 in the tradition and it is all there as well. And so you've got this northeast training and then you go way out west for training and cardiac surgery. What was that experience like back? This was, 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 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 immunologist. And then I was, you know, 10 years into this, and then all of

us 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 of 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 60, 7. In the 60, 66, 67, it was when Christian Bernard down in South Africa did the first transplant. And then after that, there were 100 done in Texas, and then most of those patients died, so it was 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 washed 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 gonna go back to South Africa and do it. And so he did it. Shumway from that 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 the 150 or 30 like in Texas, and then they would just leave

it totally because the patients died. Well Shumway 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, so with the immunology of it, the cardiac biopsy, 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 in last year or they saw a 50% mortality, very expensive procedure of this moving hearts around in 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 Bentbriggum, 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, you know, 28 years ago, were still alive here in Nashville and around the country. So I got fed, I can get fed up, I did get fed up, but instead of staying at mass generalized that, 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, where it all continues to evolve. I mean, to me it's just such an amazing story within medicine to go back to the first

transplant 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 Starrasal. But if I think about people I wish I could have met, Thomas Starrasal would be very high 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 is, it sounds so much like what you describe Shumway doing, which is systematically in the face of non-stop failure watching, you know, 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 extra-caporial 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? Well, 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 sound. I'm not doing this. Someway 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. You 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 so that most people have taken or understand. And the other is emurin. And we didn't have a new drug that came along in about 1982, which is cyclosporin.

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 fitting into, is that science is this evolutionary process and that the great, the Starrzell, Tom Starrzell, 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 focus 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 of the last 150 years of surgery, the modern era, then you think about the giants, the blalocks, the hallsteads, the shumways, linohan, starzel, I mean, these people, they had step function changes in the field, their existence, and the teams around them. 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 Shumware Starsle did, for example? Yeah, you know, it did. 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 replaced 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 a

lift and a heart out of somebody putting in there. And I say, yes, I've done hundreds of times. And then people say, it's a sound ride. 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 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 and not me, it's 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, putting the heart in it, just like a piece of meat you're setting in the chest. And then you just step back and as you warm the patient up, the body up, all of a sudden that inner piece of meat that you've been carrying, and it's terribly even described 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. I think, you know, it's miraculous, so I agree with it.

And you can't fully explain it, but it is. But it took the shum ladies and the stars was in 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 where it's at, and I don't know exactly when you were doing your surgery,

but taking out gallblires, these big incisions and these bloody fields in hip replacements. I mean, now that's been revolutionized through scopes and mentally invasive surgery. So that will probably continue with 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 a 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 in 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 Wrights there or had he already left for Hopkins? He was leaving it exactly that time. At that time, at Stanford, as you know, there were four cardiac surgeons and Shumway, the cardiac surgeon, who was fathered to them all. Most of the people had gravitated there because of his approach, bangs outside of the norm, not a lot of respect for tradition, for tradition sake, big believer in team approach. In Boston, you have to work 10 years to get to put in a stitch.

You had to wait your time on the east coast. If you were good at it, and you were a first year or 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 Rice came out of that tradition and he had just let them, of course, know him the well because he went to Hopkins after that. So you finish getting your, you know, basically your transplant training at Stanford and

then you head back to, is it Vanderbilt? You go straight to. Yeah. 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. No, yeah.

And at that time, we had the Stanford program, and there were a few other programs around, but each of them is simply, 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 and I want to come back to where you're going, but once we mastered heart transplant this whole field of lung transplants three years later had never been done. Never been successful, but because of that drug cypress form 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 heart lung. Yeah. So you have the heart. It seemed like taking a lung would be easier, but it's not. So combined heart lung, where you take them both. And that's what Bruce writes in Chunway 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 biased word say this is still Very costly on a cost per life basis. There's probably more efficient things that we can do with resources No, we're in this have we talked about where insurance companies are I 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 translates, you were trained by the best.

For your first 10 transplants, because we know this is anymore, just the opposite of mass-channel, we know this is life-saving to thousands and thousands of people dying across America. We also know that it's not 99 percent successful. But what we'll do for your first ten 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 outcomes. A hundred percent mortality, everybody would die, who needed to transplant, everybody would die within six months without it. And if you got it, you'll on average, 80 percent of the time, would live at least five years. And if you got beyond that, would live 10, 15, 20, 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 anesthesiologist, 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 even 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 transplantation Yeah, and there was an additional burden That at that time Shumlai was training the great cardiac surgeons. They weren't great. They were young people like me at the time but just like Bruce, 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 away. Most people think about cardiac surgeons who are in there, you don't have 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 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, could come 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, there was a guy that named Walter Merrill. Walter Merrill was Hopkins Crane, 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 two days of age, and three days of age. There was never a transplant that I was involved with that Walter Merrill wasn't there. Link, side by side, sort of this alter ego. And with that, and building the team with nurses and profusiness, they sort of shared the same shumlay mentality of team

first. Keep it simple, stupid. Don't be afraid to double dribble it. 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. 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 transplant than in any center that people are listening to us in their cities today. It has nothing to do with me, me really but it's taking that experience which again you understand that what the residence experience is and the young faculty is if

you're looking up to have a mentor and you can capture that culture and you go out and apply it. So I replicated exactly what I saw it stand for 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 transplant, the early heart lung transplant. And then ultimately obviously we had it delivered to it and we had bone marrow already, we had it pack-risk and became a large multi-organ transplant center. Now where was Debakey and Koolie 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 above stars and in some way just got there. They were excellent surgeons and they did these incremental leaps in surgery and in vascular surgery. Both of them, they're 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 didn't want 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 learn iterative process. But Debaki and Kool-Aid said, well, listen, this thing looks pretty good. It seems to work pretty well. And so they did in Texas, this all in the late 60s. So, remember, this was all 60s, 7, 68.

And between 68 and about 69, they did, I think 110 heart transplants in competition with each other, do it big, do it it Texas style and then all those patients died And they died which comes back to the story some way was out there figuring out how to treat the Heart rejection this inflammation using that little that little cannulae puts through the neck and they didn't have the Patients for that and so they shut their programs down and went on to other things and then in the the late 70 started doing a few and then the 80s kind of picked up where everybody else did. I mean, the whole story of Debaki and Koolie, 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 Debaki? I think Debaki died first, right? Yeah, they did, and the hospitals were right across the street, and never did really. I think when Debaki or Koolie got a medal of honor that there were some kind of congratulations it went on, but in essence, never, never did.

Yeah, it's interesting. I never met Debaki, but I met Cooley because he trained at Hopkins. And so every night when you're on call, when you'd be walking through the Blaylock 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 at the MGH one. And so at the Hopkins one, Koolie shows up and I'm there with my closest friend from residency who happens to be a cardiac surgery fellow about to go in and bark on his pediatric cardiac fellowship. And Koolie 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 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 gonna 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, 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 to it. I mean, he was a gifted surgeon. Yeah, and he's really there icons and contributed so much. And there, you know,

hundreds of thousands of people alive today because of people they've trained at 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 changed so much. It's one of the reasons, but they were just too talented, prodigy-type surgeons. Do you think that medicine can no longer attract that caliber of individual? Has the profession changed such that the best and the brightest would never consider medicine today. I'm not close enough to what the hot shot college kid is doing today.

But given, for example, the incredible changes we've seen in technology, is it really the case that the coolies and the debakies in the sumways 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. There are other ways to serve people that don't involve literally going into medicine. Do you ever think about that? Has there been some sort of passing of the torch in terms of the war for talent? When you think of the Stardols, the Debeckys, 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've got to be fast, deliberate, you've got to keep it simple. You've 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 some microscopes when, yeah, sure, earlier question, that sort of athletic competitive hero on the field, cowboyish sort of approach.

I think we're beyond that, just to most of the big sort of blood and guts, that kind of imagery is passed by. But to go back to your question, no, I think medicine still. It may be 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, 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 attract great, great people. And if you look at, at least here in Vanderbilt, where I'm

familiar with medical school applications, they're all time high right now. And people say, yes, but the quality is not there. And the attraction of making a lot of money or doing the next Uber 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 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 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, you know, 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, it's 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'd 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 in 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. It's all giving a 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 are 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 just spent right at 10 years learning all this surgery and medical school and how to

do transplants 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'd not been in the service, I'd not done anything actively other than learn to be a doctor and you know spend 18 hours a day doing it for for those 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, maybe not help an individual, but health of a community or health of a population. And I said, do you go run a university? I'd been on the board of Princeton University as a young alumnus and sort of solid 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. A new policy could do it, because policy could affect the world.

And I'd seen that back 20 years before when I'd been in intern during the college years. And so it said the only place is really 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, 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 he had doctors bags and he was 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, you know, run for public office.

They were not overly partisan. My mom was probably more of a Democrat. My dad was probably more Republican. And I was probably neither. You know, I was an sounding doing heart surgery every day. So it really was an extension of that earlier poll, 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 look to him. 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, in innovation, and running a large laboratory, and writing papers, and why would you leave that to go into this world of policy?

And the answer to them was what it is now. I also said, I wasn you going to state forever? I said, you know, I'm not a politician. 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 representatives I don't know how many how many seats are there in the house representatives in Tennessee? 9 okay, but to say I'm gonna be one of the two people running for Senate is 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'd spent a year and I had to leave I didn didn't have to leave, but you either do it or you don't. And this 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, and I may have said, you know, get out of here, don't do it. But that was hard. And so I systematically took about a year, this one I was still practicing, and I went to see Howard Baker. He had been a 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 around 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 that you said, to tough business, half the people are going to hate you all the time, half of them are going to like you, and 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, he the first time he didn't listen to him very much, or he'd plightly do it. The second time, you know, plightly. And then about the third or fourth time I went to say, 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 the in the early 90s. Oh, this is before 92 then even. Exactly. And this all 91.

And then ultimately that seat opened up and then I had an option to running for that seat, which is an open seat 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 challenging and incumbent. And I know why because I was the fresh face and he was the person who had 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 you won by a pretty hefty margin correct? Yeah, that was I had a primary with six others Yeah, I was gonna ask you about the primary what 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 Party state was more Republican. The Western was more democratic. The middle where I live was sort of in the center. The Eastern Party of the State was more Republican, the Western was more Democratic, the middle, where I live was sort 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, you know, going to be appealing to a broad range of people.

So in our primary, there were six people, all out of that same ill. 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. So, 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. You see, always say that Iars was a clean race, and Iars was 100% cleaner than these races today. But it's all just hand-to-hand combat, this politics stuff. And so I don't wanna 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 ride 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 and 94. And that comes to the other thing, so ultimately one, which nobody had expected, nobody, chances were probably one in a hundred. And the other thing that didn't 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 on simply one. 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 ironically when you look at today were balanced the budget. Over time eliminate the debt. Keep taxes small. So those were sort of the big issues. These big physical issues that were out there. Wellfare reform 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 go back to the first point you made, which 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 94 was the same thing. Now how did you learn the mechanics of the US 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 an inferiority complex, like I didn't learn US history growing up. So I, you know, I'm, you asked my daughter, she's like, Dad, why are you always grilling me on US history? And it's like, Hey, 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, AA, and little league baseball. Like how do you learn all of that stuff? I mean, was that the, I mean, if the first time

you're doing a transplant by yourself is scary, I would think the first day you're sitting on the floor of the U.S. Senate is 10 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 the worst part was the first, 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 Order. There's not a book you read. There's a little book of rules and you'll hear about it every two years after past 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 all the other stuff. And I had zero. You gave me a 30-page book. It's like it's 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 fast, you need to do it hard, and you may do it for a month, 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 advantage. I was able to come in as an outsider as a physician. Somebody who has looked at to be trusted, somebody that has looked at to be fair, somebody who learns predominantly. Not the way a typical politician does it, that I know better than you. It's, I got to listen. If the patient comes on the door, which I've 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 shape complaint or that last, you know, look and 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's a pretty big advantage. I didn't realize it at the time, but by listing very carefully, by working with trust and upholding that trust, 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, you know, how, 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, you know, I've been in the United States Senate about as far from real people as you can get. And so all of that came as real advantages. And again, I didn't know it. There hadn't been a doctor there. I told you since, you know, 1928 or elected since 1928. So that was it and kind of stuck with that throughout.

But it wasn't the healthcare issues. When there was a healthcare issue, it would all come to me immediately because the time healthcare was probably, I don't know, 16% of our economy. And yet there was nobody in the chamber who would ever take 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, slightly 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 that'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, no one exaggerates, 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 18, 10, there were, I think like 25 or 24 physicians in the Senate over a six-year period in and out. If you look at the next 50 years, 1818-50, it was 12, about half of that. And if you look at 1850 to 1900, it 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 were talked about earlier that, you know, 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 then doctors wanted to focus on their work and therefore they didn't put themselves out there. And then even after I got there, 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

of boys 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 aversion to them. It's really that people from the science world didn't move in that direction. And the good reason is not to, I mean it tells you, it tells your life apart. I mean you give up all your privacy, families are destroyed, yeah, 50% of the country hating

you, not hating you, exaggerating, but... Well certainly today. Today, yeah, 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, you know, even in my 12-year period, we addressed, I was not the lone voice, but I spent a lot of time explaining what science is, and as 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. You just been two 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, seven million people, I was served for 12 years. I've got a job. I believed very much in a concept called the Citizen Legislature. The concept that somebody goes is 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, DC, to serve as a citizen legislator. The citizen, the broad experiences, the trials,

the tribulations, the challenges, 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 the 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 and taking care of acute medicine and chronic medicine and mental issues and 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, maybe brighter or smarter or bring their citizen ledger to slightly

experiences there. Social media was a philosophy for me. And again, the right one to do, it did allow me, in my last term, to focus on instead of fundraising and having to cast boats in a certain way that looked politically good and that sort of thing, which is just part of the business, it allowed me to have a clean slate, do it off the 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, I personally, I find that to be a very appealing idea. And initially I did too. And you have to met those first days going in. And I think of those first days

Just as an aside my dad. He was a doctor came up to visit me and he said on my door. It said Mr. Bill Friss and other ones said the honorable Bill Friss and there's in these gold plates on the door and on your chair on the Senate floor And he walked around and he grabbed him by the army walked me back down the hall and said son, you know, 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 first there. And so that whole world of being a senator for a period of time, sort of renting the, 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 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 when I got into leadership, all of a sudden who did I turn to? I'm not smarter enough. I'm sort of, you know, every sort of intelligence overall and I worked really hard. And so I would turn to the person who had 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, 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 this this this crucible on this 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 you know I'm just gonna stay for for 12 years so and then go back and do other things but I do think that's a mixture 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 mean, the middle of a 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 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 DC 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 as this brand new? And the first six years and the last six years were different for me. I served under two presidents, one of 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 and 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 of about four or five years, that

became the junket. And so every New York time and Wall Street trying 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 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, the 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 there'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 critical 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 and past politics has played that out in our history. That, you know, hiding things in the long run is unhealthy and destructive to our government, to our, the fundamentals of our democracy. I think what changed it all is that what we're seeing today more than even when I was there, but is the misinformation that campaigns. If the media like on this whole thing of co-dells 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, it was much harder to counter. But it was same sort of stuff. 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 to disappear.

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 that. 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. That means you have to agree, but this connected of saying two sides of things. And you 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 the bank ironically before, but it's not the reason I went on it, but Pete Domingo she was on it, and when I was choosing my committees, the way committees are chosen, I was 100th in seniority so i had ninety nine people of the were you the only freshman senator elected in ninety four no there are others elected but the ones if you served in public office before got it you get credit for you've been a governor you get credit for it yeah yeah so you

are the lowest total yeah i'm not all i was okay been a heart surgeon and taking care of the opinion saving their lives when i got up there, but they kept care less. Especially when it came to committee's joyous, or it came to anything that had to do with appropriations or power or that sort of thing. But the committees, I ended up with 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 shared 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 to 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 and 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 re-election. 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 year to end, jump to number one in a period of six years, that sounds crazy. And it is crazy. And, and, and, and Lyndon Johnson did it, but he'd spent all those years over in the house of representatives, but they, they 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 re-election. At the time, Bob Dole, who is just an iconic leader as well, and Trent Lot and others were sort of the Trent Lot representative, a younger generation, but all very senior to me were sort of added each other and competitive, and sort of the intrapamely politics and class office sort of stuff.

And I didn't pay any attention to that really. What I was interested in, and I used this in different ways today now that I'm out of politics. And 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 will 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, depending on how you look at it, in the federal Republicans, either 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 Dole, I recruited John Thunne. 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 then and that leadership I did this one. 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 and 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 and Plotter, you

suggested earlier, I ran that group. I represent the United States Senate in every state. I had to raise money for the Senate Royal Committee. But we won that year, 11 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. You know, it was all sorts of macro everything coming up.

But we won, and we won big. And so, you know, I worked at hard, and again, there's been a heart surgery. I'm not trained to do that sort of thing, there's been a heart surgery, and I 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 Nebraska. I'd sit down with 10 people who wanted to run 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 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 them seats in your first bedroom? No, no, no, no, no, no, no, no, 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. And the first midterm of any party of the president just, you know, just historically, nine out of 10 times loses seats.

So I wanted to keep the losses to a medal. I wish I could say it was to 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 this a doctor doing his best, you know, a good guy can bring people together, can bring the Democrats, can be 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 mostly behind closed doors in these caucuses. And when it came to elect the majority later, again, I didn't want to be a majority leader. What in 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, pet fire, these huge things that affect millions of people if you're the leader. And you look at what McConnell, if you're, or whoever's the leadership Schumer and McConnell today and whoever will be, you know, West people listen to this in the future, they don't have

time to do the legislation or the policy. They're out there managing, they're 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. And I didn't want to spend four years hurting 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 majority vote.

And one might have 12 votes, and one might have nine, and one might have eight, and one had four, and six, and then you'd get together with other people. And I wouldn'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 these, 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 a majority of the year. So I don't really toll that story publicly, but I think it is important for people to humanize this 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 the story. It did not's the story.

It did not have the credentials, didn't want it, didn't want the two-year job, so I could go back to Apollo and say, but the two-year job did well, but got lucky, really lucky, and won, and then at the end of the day, because, in part, because of this doctor thing. They also saw me as somebody that is non-threatening. They said, 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 transplant, you know, my year at the end of going to DeVanderbilt and saving lives every day by just doing my job. And 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 your 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 of is PEPFAR, which you've alluded to. Now, I've always found

it interesting how little Americans understand PEPFAR, and yet, you know, 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, they hold the administration in such high regard. And yet, for 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. Yeah, you know pet barred. Let's start with telling people what it is. Yeah. Yeah. Yeah. Let's talk 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 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'd 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 in. And President Bush, this is 2000, had never been to Africa. I made me, he'd been one time when his dad was President for a night. In conversations with him, and other people, Tony Faucici, everybody's heard a lot about today, it was a huge part of it. I 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, St. Tony Fauci down to Africa. Is this something we could do something about? He came back in a surprise way at the State of the Union Messians 2003, when I was majority later, I knew it, and probably five or six other people knew it. Basically, I 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, HIV-A's. At the time, Republicans in 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 talked 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 in 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? Howard, 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, it was the $65 billion because subsequent presidents have

continued with that program coming forward. But the interesting thing is it came from a way out to the right. And it came from the people to the right and it came from the 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 in. So it will be legacy and legacy changing and then the spin-offs from it, oh, that money is spent. It's not just on HIV age. It's on tuberculosis, malaria, infrastructure, surveillance, putting clinics in 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 puts 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 mind or the switching's interesting to sort of go through what stem cell research is because the changing of the mind 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 this Senate as a position, I know brain death well because all my donor patients, I'm involved in all of those. In immunology, when I came to the Senate, I was in and you know, did things like disability, policy, and health. So people came to me on this particular issue coming in. And there was a minute back in 1996, which basically banned federal funding of STEM's 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 that was like, back in those days, it was like a copying machine. You can make unlimited copies of it. No other cell ever in the history of man had what you 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. See 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. 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've got pro-life pro-choice, 50-50 in America. Pro-life people said that the embryo has the full genetic code. It is all you got to do as nourish it. It is a human. America, pro-life people said that the embryo has the full genetic code. It is all you got to do as nourish it. It is a human.

It may be early on, but it's in the first stage of development. So the ethical issues there were 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 is, a fascinating issue. So Bush said, now 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 seven-eight 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 had written, gone to the floor of the Senate and said, I think that here 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 is okay and local funding is okay. That's outside. But for federal funding, let's limit it, like Bush, he limited it to 78 cell lines. I said, instead of doing that, let's sort of stay with the times and use these blast

assists to 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. 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, discarded. So my argument in my 10 principles that I went to the floor

in 2000 was that used 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 part of senators today. Science changes over time. You learn things. They're better techniques. There's evolution of knowledge, you clinical trials proved 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 the President Bush did not agree with me and the majority of the Senate and the majority of the House. We passed the 2005 Bill called the, I think it was the Stim Cell Research and Enhancement Act. It passed. It says you could use these blast assist. An ethical construct was set up.

You got consent set up. And then that bill passed overwhelmingly by partisan, but it was vetoed by President Bush. And so then people said that Fristan Bush are in totally different areas. But for the day one, the embryonic themselves, to me, it'd be a heart transplant certainly where the most exciting science had come by in 10 years. But when this whole ethical issue came out, out of both my own beliefs, you know, 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 you got created and now we jump, you know, 10, 15 years later, the same principles that I had put in a 2000 and 2005, the ones out there. And that's where that research is going. 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 dubblings, and become cardiac myocytes? And this subset of you are going to go on to develop Prokhenji fibers in 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 this Dem cell so it's this is step one of 10 basically in in terms of that.

But it's hard to tell people that and as a policy maker 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 have 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 injury, 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 concepts of life. And that's the tough job of a policymaker. You got, you know, 100 regular people there who, you know, some are smart, some are not

that are, you know, maybe not perfectly representative of people, but they got to make these decisions. So, you know, it's the sort of thing that, you know, at the end of the day, we increased federal funding for STEM cells, constructs were put around it, imperfect. His approach was different in mind. People made a big deal about it at the time, but, you know, 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 capital 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 policy maker 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. We 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 kind of president veto any amount of majority any senate majority he can if the ninety nine senators are in favor of a bill the president can still veto it well yeah it's

a good point because you if you can have a majority of votes for it or a super majority but you have to have two thirds or three fours come back so if you vetoes you have to take a whole not vote. And then override that beta. So here she has that intervening time to put, you know, 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, 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 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. Like 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, you know, 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, Terry Shiveaux. And I guess just for folks who don't remember this, this, and you can correct me on some of the details, but my recollection, because I was in residency, this was such a, 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 million equivalents, 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 on 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 US Congress. Yeah, it is a fascinating story. And one again and you know i haven't talked about uh... a lot in part because it is complicated and you do need the sort of the time and we can do it very quickly but no no we don't have to do it quickly yeah yeah no but now it is fascinating case and it because it has implications for

everybody listening to us today, everybody. And it will be, have even greater implications in the future as technology can do these miraculous things. Here it was miraculous in the sense that she 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.

So you're exactly right. 1990 Terry Shiveaux, CLABS, Hypochalemia 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're on a ventilator and you can move and I open your eyes, but it's just you have to be supported overall with both feeding tube as well as a ventilator. And Michael or a husband did everything, at least in my review at the time, he took

an UCLA, took it to multiple centers and for rehabilitation. And then the three years later in 1993, he'd given up basically, and I don't know, I wouldn't have both found me in that, this is ten years later than 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. I do not recess today to remove the tube. So you had this dichotomy of walking the room just like you said, Bruce did.

You had a 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, look in 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 listened to 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, you said about Catholic. She values life, and you had the four of them saying, you know, we'll support her, we'll take care of it. We'll take care of it. And then you had Michael, who by the law would have that responsibility of saying to you and our 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 and I as doctors could overstate the importance of an advanced directive enough. And I think a lot of these issues could be resolved if, well, 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 that might not have the medical, my wife's a nurse. So, you know, we could talk about it through. Well, I would tolerate this many line changes at this many weeks of a trache and this feeding tube, 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 whether 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 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 nervous. So, jump they had seven years. Her feeding tube was taken out, then a court, these courts as you said, can a came man 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 was 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 and they'll be okay to withdraw therapy. Take the two, I'll take her off the ventilator. The two who voted against that said no, she's in a mentally conscious state and can't 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, their equivalent of their house and senate, the legislators got together and actually passed a law in that six-day period that gave Governor Bush at that time the order to put the fitting two back in. All those over the 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 Rights 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 to throughout the public. 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 of the sister of the parents said, 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 Brandeis was involved in all those discussions, and when I was at Stanford, the ethical issues, the disability policy, the only physician. So I had 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 what I came down to. And the question is, which part of the family you listen to, the one that the law would give it to, ultimately, it would be the husband, or all of the siblings and the loved ones and the people who 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, the operating room, and there was a spouse who said, no, as he said, take the heart, it's okay, but the rest of the family said, no, we don't want you to desecrate, you know, the body of our loved the ones who take the heart, even though the law would say I could do it, you know, into these donor laws that we have, I wouldn't do it. Of course, I wouldn't do it. I wouldn't, to me, it's just not the right to do it.

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, and as you can imagine, it's fairly 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 it says, so I boyd 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 in that I'll disagree about something like you have a Bruce Wright's walk out and you describe that well. So the first thing I 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 a 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 see of her head that shows basically, it's mostly fluid, there's no brain matter. That was post mortem. Yeah, after.

That was after, because six months later, because then it all surged up again, as you can imagine. So talk to the neurologist, he was just happening to the last neurologist. I personally, as much as I met with the brother, it was clearly gonna 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

of Reed, was the Democrat at the time, became bipartisan, the House led on the bill. Now come back to what the bill was, and we had a bill. And it was bipartisan. It was supported unanimously in the United States Senate, overwhelming majority, both parties in the House of Representatives. And 15 neurologists had signed in Afidavit 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, you know, but this has come to us and it's an issue that cannot be resolved.

And I said, it should be rare. It should be decided locally, the way, you know, 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 passionately in the Senate in the House, I think it was like 210 to 50 something, by partisan. 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 two, that's what the husband wanted. And if not, the family should be listening to, the extended family should be lifting to. So the outcome, it passed the United States Senate, it went to the federal courts, they denied the petition and the feeding too was removed and she was allowed to die. So that's the story. So it's an interest to you and on reflection, you know, 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 policy maker, 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 you 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 effect you did 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-liberative pursuit of happiness, the oath that all those 62 lawyers and everybody taking the Senate, but it also taking this other oath, this hypocritic 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, well this may not. And this has got to be exceptional and rare and it has been in retrospect and those kind of cases haven't made it back to Congress and these decisions clearly, clearly, clearly are best made locally. The other challenge, you know, closing 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 say here you have Senator Chris, Chris playing doctor in the United States Senate, you know, he's 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. 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, in this case, shows that this inherent tension and challenge to our policymakers who are, 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 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 so obvious as to what the state of her brain was. I think the interesting point here is that you are 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 actually 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 you 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 understanding that politics is a part of our democracy, and

you wish. And with things so partisan, everybody wished, not everybody, but so many of us wished 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. That's why I come back to this tension that has to be there, and this discernment, and this past experience, and not arguing, you know, 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. 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, you know, 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, you know, COVID and other things, but the nightmares 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, years United States Senator, the security at that time rests 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 went when it hit. I was out in front of the Capitol and over to another senator's office in the first plane to 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 sessana head 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 said, you know, should you stop your meeting because the plane hit the cap, 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 a majority leader you give a 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 not 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 were two in life, there was 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

to go after Pentagon, they're going to hit any sort of symbolic sites and that they went to school right there. So of course, concern and word about them. 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 just as the 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 the surgery that had gone awry that I'd ever done. Now, it 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 sue 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 is different.

Do you recall like what you went through over the next two or three days? Because I mean, 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 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, like, there are, you know, I remember exactly where I stood. I remember exactly what the TV looked like. I remember moments moments that evening because none of us left the hospital for two days You still were in a state of are there gonna 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, you know, a hundred X 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, you know, 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 needed to do quickly, we didn't know if this was a single actor, 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 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 DC, you destroy the Congress, you do, 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 close together. And nothing else sort of matters. We're talking about the safety and security of our country. And maybe, essentially, the future of our country. And so we went out and I remember obviously the, the people you think or who are there, the leadership was there, of course. And the people were there, but the John Lewis is on the world, you know, spoke and we should display to the world that, that you can try to take us

out, which you can't take us out. 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, it was, it was, once we knew we could reconstitute government, if something worse happened,

it really was sort of systematic of up and run. This is how much intelligence we have, making decisions should we hit, how much intelligence we have, making decisions should we hit, help us, we should hit, should we hit it all coming back if we hit what's going to come out of snacks. 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 a nation state and it doesn't affect the U.S. exclusively. I think when you can externalize your enemy or the assailant in some way brings people together. You've got an image, you can create an image there, 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, it's up 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 that. There's no 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 biggest salts on our country that were on our soil here, whether it was anthrax with 14 or 15 people dying here and had our capital, 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. Leadership slash communication, how things are articulated and the like.

And I think that plays a big role. I think that if there had been a call to action with appropriate communication, leadership, trust, empathy, understanding that this pandemic could have been externalized, and we would probably have more rally around it instead of this, you know, what you see on social media and the 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 and total social chaos. There's going to be supply chain disruption, boom, 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 just think both administrations have, and this may come back to where we started, that my experience coming in was colored by things like HIVA, killing 3 million people a year, was characterized by anthrax, which when I hit the capitol, annoying 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, you said, 20 different speeches I gave, all basically out the same speech.

But I gave them on the East Coast, West Coast, Silicon Valley, the Florida United States Senate. The far reaches like NAND Tucket, the red far east of California, everywhere. And it was essentially the same speech as you everywhere. It was essentially the same species you said. It was called a 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 the 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 used the bioterrorism a little bit because I talked about that as well, because you could intentionally manufacture any of this and 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, eight by 12-foot room, with simple things.

And so the bow to her, 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 that could do. But no, this was outside of that. This was sort of coupled with that 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 say, oh, 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 4th, I said, I left the Senate the next year. And work has been done and people have tried to do pieces of it, but nobody has released state on it. But the six proposals I testified before, the Mar-O-Exanders Committee, about the next pandemic a month, two Committee about the next pandemic,

a month to 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 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. So, from the scientific standpoint, I mean, I wasn't any great. I mean, we say this like I could say 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 would be the case, but it's gonna take a constituents and people saying this is an existential threat.

This, you know, this COVID thing is not a deadly virus. I mean, it does say that. Well, 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 SARS-1 or MERS. And there's a sweet spot. Obviously, if a virus is so deadly that it basically knocks trans... 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-CoV-2 is actually quite

far to one side, which is it's so nonlethal that it's so contagious, but 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, what, you know, 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 was funny with the Marge committee, He ran the health committee with 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 listening to the hearing and give my testimony. But, you know, 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, of course we do. And we're doing everything we can, but look what history has led us to. And 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, that's the sort of thing. And public health infrastructure locally. They're fewer public health people on full-time payroll in our communities today wherever you are right now than the where eight years ago. Public health people, public health has been the stepchild of health and welfare and healing. That is, it's inverted now when people appreciate it, but we can actually deliver on 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 in 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 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 we could 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 sub-optimal, it's going to get better? Yeah, you know, I, 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 get 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 make it 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, you know, we are going to figure out in some way to curate social media in a way that still allows, you know, 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 kind of take a little bit further, but I think we're gonna get better there. When we get better, that will pretty much better stay because it was still on the curve of getting worse and may get worse in other, you know,

this world populism, it may get a little bit worse, but it will get better. And I'm optimistic about that. Leadership, I think it's 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 a world, but came in, and every

other Friday would take three people from the Senate leadership or four to Republicans to 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 things, but you'd have the people who are the leaders around the table, and people like Nancy Pelosi and President Bush sit inside by side for breakfast for an hour. There's a little bit of attention there.

But this was before the Iraq war and things got really complicated in so many ways. For that period of time, things seem to be so much better, really uncomfortable. I don't know if people have talked about that either. But what I say that in preface that because I do 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 know, you just don't know. But I do think if you had at that level, not at the level of a Chuck Schumer and Mitch McConnell, you know, it's too ingrained to 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

take President Biden or President Nixon 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 the 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 it's sort of my experience. In my thoughts, it could be as easy as that to begin the turn the tide. And I think we'll see that. I don't know if we've been in 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, you know, how you elect somebody who really will do that from a very partisan group, it makes it hard, but it's doable. And we're talking about regular people and people who, you know, 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, but I think it can be done. I think it probably will be done. But I think it can be done pretty quickly, I think. There's a real call from people for the sort of bringing people together. It 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, you know,

as we did sort of more of my first term, then in my second term in the Senate, sort of shaking hands after you have a big debate on the four 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've, you know, you're doing venture capital, you're on the board of four 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. It's a little bit like they look at you, probably, if you look at your past thing,

you know, you've done different things and you've tried different things. And is there any sort of narrative or a 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. And, you know, 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, you know, 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? I think 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 the HIV, AIDS globally, and I came back to one thing, and it was K-12 education. And globally, probably, K-12 education for girls. And if you're going to spend, you know, a increment of time with my experiences, where would it be? So what I did to start a foundation, it's called State Collaborative on Reform of Education.

It's by far the biggest thing in the state now. I started, but got really smart people and good people, dedicated people to run it. And with that, it has had an impact where Tennessee has, for the last 10 years, shown dramatic improvement in K through 12 education. It has been recognized as such. So that is a little bit out of healthcare, but the nexus between health and education is so real. The health feeding end to being better educated, the more educated, 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, she goes, 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 describe so well

in your talks, you push that downslope on the chronic disease and the age you got as far as you can, but at some point you come to those graphs that you drop and you're going to bring things to a closing 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 down to hill, you're family, if you have family, local, that don't know

what to 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 can 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 gonna die within six months, flying in, coming in, saying, we need a transplant, and I say, I don't have it up 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.

You know, they wouldn't come here, if Dr. Hayden told them it was going to be six months, but they lived eight nights, nine months, twelve 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 nutritional, that looked at the exercise and sort of generally cute care, medical care as well. And so that's sort of a good example of the sort of company,

is that I believe in it, ties things together, there are needs that are out there, 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, you know, 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, you know, Shumway figuring out that cardiac biopsy to determine inflammation and and then developing a new drug like cyclosporium which revolutionizes that field. It's doing it the business where oh yeah, you have access to capital, you can move fast. You're not slowed down by government. So it's pretty, 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. I don't know. I think the trajectory of your career was very interesting. 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 talk about the look on your face. You're probably glad you're not.

I'm just fine. It's been a pleasure speaking with you today and I thank you for all your service. Oh great, it's a 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 lot of you to be with you. Thank you. Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics

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