#150-Senator Bill Frist, MD: A modern Renaissance man's journey through science, politics & business

1. 0:00 – 3:40

   Intro

   1. PAPeter Attia0:01

      [upbeat music] Hey everyone. Welcome to the Drive podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all 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 wanna 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 wanna learn more now, head over to peterattiamd.com/subscribe. Now, without further delay, here's today's episode. [upbeat music] My guest this week is Senator Bill Frist. Senator Frist is a former transplant surgeon. He's a pilot, though we don't even get into that in this episode, it's just a whole other amazing story. Obviously a politician, businessman, healthcare policy expert. I mean, he's, 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 nineties when he up and ran for the U.S. Senate in nineteen ninety-four, having never held public office before. And perhaps even more remarkably than that, he was elected as the eighteenth Senate majority leader in two thousand two, taking him from the single least senior person in the U.S. Senate to the most senior person. We spend a lot of time talking about his journey through medicine and ultimately twelve years in the Senate through some of the difficult policy decisions and the controversial decisions that were made. Since leaving the Senate in two thousand six, Bill has done a number of things. He sits on the board of more not-for-profits, for-profit companies than you can count on. Probably spent a decade really focused on private equity before now shifting his attention to more venture-based funding. He also hosts a podcast called A Second Opinion, and we get into about two-thirds of what I had wanted to get into here. That's how much I wanted to talk about. But it's really a remarkable discussion, and one of the most interesting things about Bill that we do touch on here is that in two thousand and five 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 nine eleven. 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 gonna be a question of if we have a major pandemic, it's a question of when." And these were the things that needed to be in place, and these are the likely things that are gonna happen. And, you know, unfortunately a lot of those things came true and, and we weren't really ready. So we spend a little bit of time on that. And, and finally we talk a little bit about just the current state of politics. And even though this isn't a, a podcast about politics, I think most people in the current environment can't help but acknowledging that we're in a bit of a strange environment. And we talk a little bit about his, his optimism as to how things might get better in the future. So without further delay, please enjoy my conversation with Senator Bill Frist. [upbeat music]

2. 3:40 – 12:00

   Bill’s decision to pursue medicine and do organ transplants

   1. PAPeter Attia3:42

      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, uh, it would've totally been understood if we needed to.

   2. BFDr. Bill Frist3:53

      Great to be with you, Peter.

   3. PAPeter Attia3:54

      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 'cause, you know, you talk to your patients that way, right? Like-

   4. BFDr. Bill Frist4:09

      Yeah, yeah

   5. PAPeter Attia4:09

      ... 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?

   6. BFDr. Bill Frist4:20

      You know, the, there's two things come to mind. Number one, uh, most common thing I get, "Do you get called Senator or Doctor?" You know, people who wanna be formal, and of course I say, "Call me Bill." But, but, uh, that is a harder one because in, in the Senate, you know, especially today, people are kind of down on the, the, 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 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 Mister if they were two, four years older than me, and it may sound crazy to a lot of people. Listen, that's just sort of the Southern way of doing it. And I remember going down working with a cardiac surgeon, and right in the middle of the case I said, "Yes, sir." And you're not supposed to say sir either [chuckles] , it's kinda like the Mister. And then he turned around and me and said, "Don't you ever, ever say sir to me again."

   7. PAPeter Attia5:12

      [laughs]

   8. BFDr. Bill Frist5:13

      Isn't that funny? It's just, uh, d- depends on where you are. You're exactly right.

   9. PAPeter Attia5:17

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

   10. BFDr. Bill Frist5:22

       You know, I, I had a, a real sort of fortunate circumstance in that I was the last of five children, and my dad was a family practitioner, a doctor, and my older brother, who was fifteen years older than me, went into medicine, so he was a doctor. My middle brother ended up going into cardiac surgery, so he was in this track. And so I pretty much assumed I would go into medicine or, or nursing or the healing profession from very early on for that reason. I saw the gratification. I saw the, 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, my mind, and 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, some shape or form.

   11. PAPeter Attia6:19

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

   12. BFDr. Bill Frist6:39

       You know, in, in high school and in the early years of college, I interned in Washington, DC for Congressman Joe Evans from Tennessee at the time. I spent a summer writing for a newspaper, The Nashville Banner, no longer a daily newspaper here in Nashville. So throughout, it was always being interested in the broader aspects of medicine, of being a doctor. And I had no idea, and I didn't have any master plan with it. But I guess at every stage, and now that I look back, it gets reflected in my life, that I always had other parallel interests going on. And as, as you probably know and recall, I'm a, 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 wanna 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, and not being in a pre-med track at, at Princeton, but still wanting to go to medical school, you know, even the medical schools had a little bit of bias about coming in, at that time, very different today, if you didn't demonstrate working in a lab and, and all those other pre-med track things in those college years.

   13. PAPeter Attia7:56

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

   14. BFDr. Bill Frist8:06

       Yeah. I don't know, but it, it's, it's there, and the tradition, man, is all there as well.

   15. PAPeter Attia8:13

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

   16. BFDr. Bill Frist8:23

       Early '80s, and it's actually interesting in many ways, mainly in retrospect, o-of course. But I went to Harvard Medical School, and then I did the six years at, 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 gonna do heart transplants. And you know, I'd kinda stayed at Mass General because they'd done the early kidney transplant work in, in America there, had great immunologist, and then I was, uh, you know, 10 years into this, and then all of a sudden the board of trustees and the broader community said, "It's too experimental. It hasn't proven itself. We can vaccinate a million people," I'm exaggerating a little bit, "for the cost of one transplant." And therefore, they put a moratorium.

   17. PAPeter Attia9:20

       Now, what was the mortality at that time? Because Barnard's first heart transplant was in '67.

   18. BFDr. Bill Frist9:25

       Mid, mid '60s. '66, '67 was when Christiaan Barnard 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 kinda shut down.

   19. PAPeter Attia9:39

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

   20. BFDr. Bill Frist9:44

       Another fascinating story, and, and Norman Shumway, who was my mentor at Stanford at the time, was really outside of the mainstream of cardiac surgeons. And, 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 fig- fig-- this heart transplant world, systematically with discipline, not taking it to people until they figured out the science. And then Christiaan Barnard came in, he watched a little bit of this. He was from South Africa, and more in an opportunist way, he said, "Well, 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 mid-'60s to when I got involved in the early '80s, systematically had a program where other programs would do the 100 or 50 or 30, like in, out in Texas, by the way, and then they would just leave it totally 'cause 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 of it, the immunology of it, the cardiac biopsies, the instruments of it, and in a very deliberate way. And I tell that long story because it really had a huge impact on, on me that the science is really fundamental. It's important. Until you get the science right, you should not be taking this to the clinical world. Know the facts, get rid of the misinformation, do clinical trials, don't prematurely take things to the field. And so at Mass General, they saw a 50% mortality, very expensive procedure of, of this moving hearts around and the, and the immunology and the equipment that was required, and they said, "The greatest good for the most people is to not do heart transplants at Mass General or Peter Bent Brigham or Beth Israel or Boston City." To me, from my perspective, I said, "Are you kidding me? You know, we have, uh, 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 ten, fifteen, twenty, thirty years. People I transplanted,

3. 12:00 – 21:45

   The miraculous nature of organ transplants: History, Bill’s work, and the most exciting things to come

   1. BFDr. Bill Frist12:00

      you know, twenty-eight years ago are still alive here in Nashville and around the country. So I got fed... I didn't get fed up. I did get fed up. But instead of staying at Mass General, I said, "I'm going to California to train with this one person in America who systematically had spent twenty years developing heart transplantation," and continued to do that because the overall field, the overall heart transplant world continues to evolve.

   2. PAPeter Attia12:24

      I mean, to me, it's just such an amazing story within medicine to go back to the first transplants within kidney and then to look at heart. And, and, 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, I'm sure you probably met Thomas Starzl. But if I think about people I wish I could have met, Thomas Starzl would be very 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 nonstop 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 extracorporeal liver. So if a person is in liver failure, they are going to die. There is no temporizing measure. And I don't remember the numbers 'cause it's been so long since I read it, even for the second time. It's a book I've read twice. But I... One thing that stuck with me when I read it, which is, one, is the belief that you have to have that this is gonna get better, and two, just the personality trait that says, "I'm not gonna get broken by short-term failure after failure after failure 'cause 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-- uh, what was your, uh, immunosuppressive regimen? I mean, prednisone and, and MMP. I mean, what... You didn't have much.

   3. BFDr. Bill Frist14:02

      Yeah. And it comes back, and we're seeing it today with today's technology, which is even moving faster. But these great breakthroughs which require this deliberate thinking in the spite of these challenges that seem insurmountable, there were technological mechanical ones, like doing a cardiac biopsy. All these patients were dying early on because the heart would reject, get inflamed right afterwards. And so then the typical surgeon would walk away from that and say, "I'm not doing this." Shumway said, "Okay, well, let's figure out the inflammation." So developed an instrument that you can go through the neck into the heart. It sounds terrible, but it's real simple. Can do it in three minutes. And figured out how to, to, to address the inflammation, to diagnose it and treat it. And then you... And the medicines that, 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, uh, that, uh, most people have taken or understand, and the other is Imuran. And we didn't have a new drug that came along in, uh, about nineteen eighty-two, which is cyclosporine. When you added that drug, which was serendipitously discovered from a fungus over in, I think, Sweden or Switzerland, when you added that to the cocktail, all of a sudden, the mortality, which may have been at fifty percent, went to twenty percent. Just that one addition, 'cause 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 in-infections. But I think the im-the impo-important point in all of this, which I think you're, you're leading and, and I'm sort of feeding into, is, is that science is this evolutionary process, and that the greats, the Starzl, Tom Starzl, University of Pittsburgh, did all transplants, but the world icon leader in liver transplants, which was about two or three years behind heart transplants, and the Norman Shumways of the world had that deliberate, that discipline, that focused process in taking these insurmountable challenges that were impossible to do and systematically, over a period of time, capturing the best of the best, even when there are lots of losses along the way, ultimately be successful.

   4. PAPeter Attia16:19

      This is just kind of a broader historical question of surgery. When you think back over the last hundred and fifty years of surgery, the modern era, right, and you think about the giants, right? The Blalocks, the Halsteads, the Shumways, Linehan, Starzl. I mean, these people to- they, they had step function changes in the field. Their existence and the teams around them, right? When I-- 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, are there sort of from a technical standpoint or combination of technology, medicine, instrumentation, like is there something that you think is still an untapped opportunity in the way that, you know, we're talking about what Shumway or Starzl did, for example?

   5. BFDr. Bill Frist17:15

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

   6. PAPeter Attia17:43

      It is amazing though. I mean, it, 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 I wouldn't... It wouldn't surprise me if every time you did it, it still felt magical.

   7. BFDr. Bill Frist17:58

      Yeah.

   8. PAPeter Attia17:58

      It probably never wore off-

   9. BFDr. Bill Frist18:00

      Never

   10. PAPeter Attia18:00

       ... in terms of what you just explained. It's profound.

   11. BFDr. Bill Frist18:03

       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, this is done by everybody now. At that time, not that many, but now it's done in every major hospital around. But getting a call, flying off in the middle of the night, taking a heart out of somebody, putting it in a bucket with ice around it, and then putting it on an airplane, traveling for three hours, coming back, opening up a patient, and spending forty-five minutes, put the heart in. It's just like a piece of meat you're setting in a chest, and then you just step back. And as you warm the, the patient up, the body up, all of a sudden that inner piece of meat that you've been carrying, it's terrible to even describe it that way, all of a sudden, slowly, that, 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 [chuckles] it would start beating rhythmically, you know, seventy beats a minute and pumping blood throughout the body, and then that patient goes home a week later. And think, you know, it's, it's miraculous, so I agree with it, and you d- you can't fully explain it, but it is. But it took the Shumways and the Starzels and people like that to do that, and then my generation, which came right m- beyond that. And then beyond the transplant world, there are other great innovations. You remember where it's at then, and, uh, I don't know exactly when you were doing your surgery, but taking out gallbladders, we used to do these big incisions and coming [chuckles] in these bloody fields, and hip replacements. I mean, all that's been revolutionized through, through scopes and minimally 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 gonna really be exciting coming forward. So is that surgery or not? I, I'm not sure. It's, 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, and surgically putting in, uh, whether it's mitochondria, a lot of the things we're talking about with COVID and vaccines and all today, that's sort of where so much of the future is, I think.

   12. PAPeter Attia20:29

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

   13. BFDr. Bill Frist20:35

       He was leaving at exactly that time. At that time, at Stanford, as you know, there were four cardiac surgeons, and Shumway, the cardiac surgeon who was father to them all, most of the people had gravitated there because of his approach being sort of out- outside of the norm. Not a lot of respect for tradition for tradition's sake. Big believer in team approach. In Boston, you have to d- work ten years to get to put in a stitch. [chuckles] You had to wait your time on the East Coast. If you were good at it, and you were a first-year intern, if you were a fourth-year medical student, and Shumway saw you operate, he would let you do what he wouldn't let a resident with ten years of training do if you could do it. So it was more kinda 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 d- who, uh, don't follow surgery, the first assistant's the person who's a- across from the main surgeon, who kinda helps the main surgeon do the work. And what he was saying, basically, "It's not about me, it's about us as a, uh, as a team."

4. 21:45 – 29:15

   Frist’s experience building up the heart transplant program at Vanderbilt

   1. BFDr. Bill Frist21:45

      And Bruce Reitz came out of that tradition, and he had just left, and of course, I know him, uh, well 'cause, uh, he went to, went to Hopkins after that.

   2. PAPeter Attia21:53

      So you, you finish getting your, you know, basically your transplant training at Stanford, and then you head back to, is it Vanderbilt? You, you go straight to-

   3. BFDr. Bill Frist22:01

      Yeah.

   4. PAPeter Attia22:02

      Yeah. And, and you serve there on the faculty for quite some time, and you're building a program obviously, right? There was no transplant program f- Yeah, you're building it.

   5. BFDr. Bill Frist22:12

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

   6. PAPeter Attia22:40

      That's what Bruce and Norm did together, right? They did the first heart-lung transplant.

   7. BFDr. Bill Frist22:44

      They did heart-lung. Lung, ironically, you have the heart-lung-

   8. PAPeter Attia22:48

      Lung is harder

   9. BFDr. Bill Frist22:48

      ... you have the heart-lung. Yeah.

   10. PAPeter Attia22:49

       Yeah.

   11. BFDr. Bill Frist22:50

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

   12. PAPeter Attia23:00

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

   13. BFDr. Bill Frist23:24

       It was interesting. So insurance and the payers, you have Medicare, government Medicaid, and then you have the, 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 figuring it out, and then once the survival was sufficient and you were, you were qualified as a center of excellence, then they would start reimbursing you. The payer system, uh, was a little bit the same thing, and I was, uh, 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, you know, scores and scores of heart transplants. You were trained by the best. For your first ten transplants, because we know this is at a... Just the opposite of Mass General. We know this is life-saving to thousands and thousands of people dying across, uh, America. We also know that it's not ninety-nine 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 a transplant. Everybody would die within six months without it, and if you got it, you on average, eighty percent of the time, would live at least five years, and if you got beyond that, would live ten, fifteen, twenty, or thirty years.

   14. PAPeter Attia25:04

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

   15. BFDr. Bill Frist26:14

       Yeah, and they, and there was an additional burden that at that time, Shumway was training the great cardiac surgeons. They weren't great. They were young people like me at the time. But just like, uh, Bruce Reitz, who we talked about, he didn't send them to Hopkins, but Bruce came out of this very interesting culture where team was very important, where humility was very important. That's juxtaposed the way most people think about cardiac surgeons who are in there, you know, high pressure, type A, throwing instruments. You never saw that. And so when I came to Vanderbilt, east of Mississippi, Bruce was up in Hopkins. All of a sudden, all over the country, people said, "Why don't we go to these guys instead of going out to California?" So all of a sudden, within a year of me being at Vanderbilt, starting a program from scratch, I was getting referrals, you know, hundreds of people coming in saying, "I want the Shumway approach. Shumway says, you know, you're as good as he is." You know, that's the way he would talk coming in. But to answer your question, and it comes back to, to what I threw in about Shumway saying he was the best first assistant. I came here, and there was a guy by the name of Walter Merrill. Walter Merrill was Hopkins-trained, uh, 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 kinda learn about the program for Vanderbilt. And so we had this dialogue, and from day one, for the next ten 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, uh, 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, linked side by side as sort of this alter ego. And with that and building the team with nurses and perfusionists that sort of shared the same Shumway mentality of team first. Keep it simple, stupid. Don't be afraid to double dribble. If, if you don't get it perfect the first time, go back and do it again. And it's worth saying all that a little bit because I wanna jump ahead a little bit because that program, after I left, has continued to grow ten years, fifteen, twenty years later to where that program today is the largest heart transplant program in America. It does more heart transplants than in any center that people are, you know, listening to us in their cities today. And it has nothing to do with me, really, but it's taking that experience, which again, you understand the, what the residents' experience is and, and the young faculty is, if you're lucky enough to have a mentor, and you can capture that culture, and you go out and apply it. So I replicated exactly what I saw at Stanford to get it up and running those first two years, worked with a great team, and then with that, we were on the cutting edge of the early lung transplants, the early heart-lung transplants. And then ultimately, obviously, we added liver to it, and we had bone marrow already. We added pancreas and became

5. 29:15 – 33:00

   The famous rivalry between surgeons Denton Cooley and Michael DeBakey

   1. BFDr. Bill Frist29:15

      a large multi-organ transplant center.

   2. PAPeter Attia29:17

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

   3. BFDr. Bill Frist29:25

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

   4. PAPeter Attia30:49

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

   5. BFDr. Bill Frist31:07

      Yeah, they did, and their hospitals were right across the street, and never did really. I think when, when DeBakey or Cooley got a Medal of Honor that there was some kinda congratulations that went on, but in essence never, never did.

   6. PAPeter Attia31:22

      Yeah, it's interesting. I never met DeBakey, but I met Cooley because he trained at Hopkins. And so every night when you're on call, when you'd be walking through the Blalock hallway, you know, Hopkins is such a storied place. Like, it just-- there's never a piece of tradition that's not enough, right? And you'd see these pictures of the young Denton Cooley, and he was just upsettingly handsome, right? So sure enough, we're at the American College of Surgeons one year, and each, you know, as you know, every university or every medical school has their own thing. So you'd go to the, you know, you'd 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, Cooley shows up, and I'm there with my closest friend from residency, who happens to be a cardiac surgery fellow about to go and embark on his pediatric cardiac fellowship. And Cooley was talking with both of us, and he says, "Oh, what year are you in?" And I, I think I was in my third year or something, and he says to my friend, Jorge Salazar, "What, what year are you in?" And Jorge says, "Well, I'm in my ninth year," 'cause 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, and he just went on. But he said it completely seriously, like there was no irony in that statement. And, and we got such a kick out of that, but I guess there's a, there's, there's some truth to it. I mean, he was a gifted surgeon.

   7. BFDr. Bill Frist32:48

      Yeah, and he's-- they're really, they're icons and contributed so much, and there are, you know, hundreds of thousands of people alive today because of people they've trained and procedures they've done and, and, uh, really amazing icons in that

6. 33:00 – 38:00

   How the medical field can attract bright young people to pursue medicine

   1. BFDr. Bill Frist33:00

      field of cardiac surgery. They probably-- There won't ever be anybody like them again. And cardiac surgery's changed so much. It's one of the reasons, but, but they were just two talented prodigy-type surgeons.

   2. PAPeter Attia33:11

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

   3. BFDr. Bill Frist33:58

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

   4. PAPeter Attia35:44

      I'll ask you the question I get asked all the time, and, and I think you can answer it with frankly a far better lens, which is, you know, what advice do you have for for somebody today who wants to go into medicine, doesn't quite know how they wanna 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 gonna 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 wanna have in place"? I mean, what, what advice do you have for somebody to be successful?

   5. BFDr. Bill Frist36:29

      You know, where, where you started is probably still my philosophy, and I'm still active in, in teaching here and mentoring a l- a lot of people in medicine and in health. And I think staying broad, I kinda fell into that because I knew what my track was gonna 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, 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, you know, just cardiac surgery or just bypass surgery or valves, but has that curiosity throughout life. So I still continue to encourage people to, 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, um, a hobby or something on the side or write an, an article every week about it to keep that going. And I guess because I have jumped around so much and kinda changed career every 10 to 12 years [chuckles] that I see how in truth it's all the same thing. It's all health, and it's all healing, and it's all giving hope. There's lots of different ways to do it.

   6. PAPeter Attia37:59

      Let's

7. 38:00 – 47:30

   Bill’s decision to leave medicine and run for the US senate

   1. PAPeter Attia38:00

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

   2. BFDr. Bill Frist38:13

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

   3. PAPeter Attia41:18

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

   4. BFDr. Bill Frist41:28

      Nine.

   5. PAPeter Attia41:29

      Okay. But to sort of 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, the election was '96. When did you have to get serious about this? Is this like a two-year process, a one-year process?

   6. BFDr. Bill Frist41:44

      I spent a year and a ha- I had to leave. I didn't have to leave, but you either do it or you don't. And this is the advice I give people. If you're gonna 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, 'cause it's kinda hard to understand. So who do you talk to? And there hadn't been a physician elected to the United States Senate. One hundred people, two from every state. There hadn't been a physician elected to the Senate since 1928. So I didn't have anybody to call or go see who'd gone through this eye of the needle medical school and internship and residency and fellowship and practice. And that made it hard, and maybe that was a good thing. They may have said, [chuckles] "Get outta here. Don't do it." But that was hard. And so I systematically took about a year. This is when I was still practicing, and I went to see Howard Baker. He'd been Majority Leader of the United States Senate before, a centrist. I went and talked to Lamar Alexander at the time, who had been governor, but he hadn't been in the Senate. I ultimately recruited him to run for the Senate. And went and talked to Al Gore at the time, who was a senator, and had great conversations. And my fundamental question was, "Am I right, or is this just, like, you know, dreams?" And to the one, they said, "It's a tough business. Half the people are gonna hate you all the time, [chuckles] and half are gonna like you. And it's gonna be very different than medicine. But if you're really serious about it, you oughta 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 me very much and... or he politely did. The second time, you know, politely. And then about the third or fourth time I went to see him, he finally said, "Okay, you must be interested in go ahead and make the jump."

   7. PAPeter Attia43:40

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

   8. BFDr. Bill Frist43:45

      No, he was still... It was right during that period of time, and that was gonna open up a seat, uh, actually in Tennessee at the time. He was still in the Senate, 'cause this was the... in the early '90s.

   9. PAPeter Attia43:55

      Oh, oh, this is before '92 then even. Wow. Okay.

   10. BFDr. Bill Frist43:57

       Exactly, and this is all '91. And then ultimately, that seat opened up, and then I had an option of running for that seat, which is... An open seat's easier to win, 'cause 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, I don't know exactly [chuckles] why, but I went the less traditional route and challenged an incumbent. And I, and I know why, because I was the fresh face, and he was the person who'd been around for 18 years. But it was unconventional to go that route at, at, at the time.

   11. PAPeter Attia44:29

       So you ran in '94 against the incumbent.

   12. BFDr. Bill Frist44:32

       Yeah.

   13. PAPeter Attia44:32

       Is that correct?

   14. BFDr. Bill Frist44:33

       Right.

   15. PAPeter Attia44:33

       Yeah. And you, you, you won by a pretty hefty margin, correct?

   16. BFDr. Bill Frist44:37

       Yeah, and that was... I had a, a primary with six others.

   17. PAPeter Attia44:41

       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?

   18. BFDr. Bill Frist44:49

       Thank goodness it's not today, where people are get pushed out. Tennessee, until recently, and it's changed in the last four years, but until recently, Tennessee had produced senators that were in the center. The eastern part of the state was more Republican. The western was more Democratic. The middle, where I live, 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, gonna be appealing to a, a broad range of people. So in our primary, there were six people all out of that same ilk. My disadvantage was that I was an outsider. I hadn't played my political dues with the Republican Party. Number one, I was from middle Tennessee and not east Tennessee, and that was it. So w- but the, 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 six, came down to two. All races are tough races. They always say that ours was a clean race, and ours was 100% cleaner than these races today. But it's always 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, to the either extreme right or extreme left.

   19. PAPeter Attia46:18

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

   20. BFDr. Bill Frist46:26

       And that comes to the other thing, so and, and... 'cause ultimately won, which nobody had expected. Nobody. Chances were probably one in 100. And the other thing that did happen, and 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 beat an incumbent United States senator who came in and so ultimately won. But there was the luck end of it, being at the right place at the right time as well. And so the policy issues, issues, ironically, when you look at today, were, uh, balance the budget. Over time, eliminate the debt. Keep taxes small. So those were sort of the big issues. They were these big physical issues that were out there. Welfare reform was just talked about in that period of time. Ultimately, the bill passed about three or four years later. But those were sort of the three big issues.

   21. PAPeter Attia47:29

       And just to go back to the

8. 47:30 – 55:30

   The value in having scientists and physicians in Congress

   1. PAPeter Attia47:30

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

   2. BFDr. Bill Frist47:42

      That's correct.

   3. PAPeter Attia47:44

      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, the same thing. Now- How did you learn the mechanics of the U.S. Senate? I mean, I gotta tell you, I find this stuff really interesting, Bill, just in part because I grew up in another country, and I have a, an inferiority complex. Like I didn't learn U.S. history growing up, so I... You know, my... You ask my daughter, she's like, "Dad, why are you always grilling me on U.S. history?" And it's like, "Hey, I, I'm trying to learn this stuff with you." But oh my God, trying to figure out what the whip does versus the minority leader versus this and what, you know, what this means in this bill versus that. I mean, it just strikes me as when you go straight into the U.S. Senate, that's like going straight into the Major Leagues, never playing Triple A, Double A in Little League baseball. Like, how do you learn all of that stuff? I mean, was that the sca-- I mean, if, 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.

   4. BFDr. Bill Frist48:49

      Yeah. It, it, it was, um... 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, I knew I would win. So that, the, the worst part were the first, the November to January equivalent, twenty-second or January fourth, not knowing what all this is about. The Senate doesn't have a Robert Rules of Orders. There's not a book you read. There's a little book of rules, and you'll hear, you know, you, you hear about it every two years. They have to pass the rules. But it's like a 30-page book. The real book is precedent that's set, and precedent is experience. It's being around. It's age. It's knowledge. It is, it is, you know, all the other stuff that I had zero. You gave me a 30-page book, you know, it's like, it like in medicine or going to a new rotation in your residency. You know, you just hop in and do it, and you do it fast, and you do it hard, and you may do it for a month, and you'll have to switch the next month. So that would've been easy. The, 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, 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 is looked at to be trusted, somebody that is looked at to be fair, somebody who learns predominantly, not the way a typical politician does, in that I know better than you. It's I gotta listen. If the patient comes in the door, which I had done for the previous 20 years, I wanna size them up. I wanna listen. I wanna look at the body language. I don't wanna say anything until they give me that chief complaint or that last, you know, look and... or, 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, a healer or a nurse, is that listening, that empathy component is part of the culture, but really the being. It is in the DNA of physicians and nurses and, and counselors and, and healers. The room I walked into had 63 lawyers. 63 lawyers. I walked into that chamber and, and that chamber, every chair was full with somebody who had, for 10 years, had been arguing legal cases and, and all. And so you'd say that's a disadvantage. Again, it ended up being a, a pretty big advantage, and I didn't realize it at the time. But by listening very carefully, by working with trust and upholding that trust, 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, [chuckles] 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, it wasn't healthcare issues. When there was a healthcare issue, they would all come to me immediately because at the time, healthcare was probably, I don't know, 16% of our economy, and yet there was nobody in the, the chamber [chuckles] who'd ever taken care of a patient or written a prescription or been involved at all. And so that kind of information gravitated toward me as well.

   5. PAPeter Attia52:19

      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?

   6. BFDr. Bill Frist52:51

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

   7. PAPeter Attia53:02

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

   8. BFDr. Bill Frist53:04

      So, so it's more. But if you look at historically, and you sorta start now and go backwards in 50-year increments. I don't wanna exaggerate, but I'll give you just the image. In the first 50 years of our country, the sort of 17 sort of 50 to 18 or 1810, there were I think like 25 or 24 physicians in the Senate over a six-year period, in and out. If you look at the next 50 years, 1800 to 1850, it was 12, about half of that. And if you look at 1850 to 1900, it was about half of that. And then 1900 to 1950, it was about half of that till 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, that we've 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 it... People were discouraged, and then doctors wanted to focus on their, on their work, and therefore they didn't put themselves out there. And then even after I got there You know, physicians don't support the political system that much. They don't get involved in policy or politics, and I think it's been to the detriment of patients and America because physicians are, are the best voice for three hundred m-million people because they're listening to their problems and their challenges and, and the socioeconomic and the diversity issues. And so they should be, uh, more interested. And so I don't think it's, it's really that the body itself had a, an aversion to them. It's really the people from the science world didn't move in that direction. And there are good reasons not to. I mean, it tears your, it tears your life apart. I mean, you give up all your privacy, families are destroyed, uh, you have fifty percent of the co- the country, uh, hating you. Not hating you. I'm exaggerating, but-

   9. PAPeter Attia54:57

      Well, certainly today. [chuckles]

   10. BFDr. Bill Frist54:58

       Today, yeah, you, you really do. So I can't fully explain it, but I can tell you with the sort of issues that, that we are confronted with today and the issues that I ultimate-- You know, even my 12-year period we addressed, I was not the lone voice, but I spent a lot of time explaining what science is. And 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, on the chamber floor.

9. 55:30 – 1:00:30

   A discussion on whether or not senators should have term limits

   1. BFDr. Bill Frist55:30

      There's just been too few of them, I would say, over time.

   2. PAPeter Attia55:33

      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 gonna seek higher office thereafter. Why were you so confident to make that assertion? I mean, most people who would serve in the Senate would wanna 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?

   3. BFDr. Bill Frist56:09

      Yeah, I actually told the people of Tennessee, seven million people, "I'll serve for 12 years. I've got a job." I believed very much in a concept called the citizen legislator, the concept that somebody goes-- It's at the federal level. That goes, they leave their home, they leave their, the people, they stay in touch with them, but they go to Washington, D.C. to serve as a citizen legislator. The citizen, the broad experiences, the trials, the tribulations, the, 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, 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 i-itself. It was just clear to me, and that perspective came from medicine. The breadth that a clinical person has in taking care of acute medicine and chronic medicine and mental, and issues. In the transplant world, you're taking care of all of that, that the world is much broader, and that you've got a job to do, and after it's done, leave. Let somebody else who may be brighter or smarter or bring their citizen legislator experiences there. So it should be... It was a philosophy for me, and again, the right one to do. It did allow me in my last term to focus on, on instead of fundraising and having to cast votes in a certain way that looked politically good and that sort of thing, which is just part of the business, it allowed me just to have a clean slate, do what I thought was right, and move ahead.

   4. PAPeter Attia57:56

      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, I, personally, I find that to be a very appealing idea.

   5. BFDr. Bill Frist58:19

      And initially, I did too. And you asked about those first days going in, and I think of those first days, just as an aside, my dad, who was a doctor, came up to visit me, and he said on my door, it said, "Mr. Bill Frist," another one said, "The Honorable Bill Frist," and there's then these gold plates on the door and on your chair on the Senate floor. And he walked around, and he grabbed me by the arm, he 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 Frist there." [chuckles] And so that whole, whole world of, of being the, a, a senator for a period of time, sort of renting the-- occupying the office but not owning the office was, was one. To answer your question, no, I think term limits would be a huge mistake of the United States Senate. This job is, is, is complicated, and it's equally complicated to heart surgery and, and, 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 gonna come through you, every one, 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 smart enough. I'm sort of, you know, average sort of intelligence overall, and I work really hard. And so I would turn to the person who'd been there for 18 years or 24 years, and I would ask what it was like 20 years ago or 25 years ago. What is the precedent itself? And not go to some staff member who's 25 years old, who's very good but hadn't been around. And that would not have been possible. That would not have been possible if there weren't A handful or 20 or 30, I don't know what the number is, of people that are there. And so the system works pretty good when you have this, this, this, this crucible, uh, this, this mixture of people like me who say, "I'm not staying any longer," or Bob Corker,

10. 1:00:30 – 1:05:30

    The highly polarized nature of politics, and how we can fix it with empathy

    1. BFDr. Bill Frist1:00:30

       who I helped recruit to the Senate, who said, you know, "I'm just gonna stay for, for 12 years, uh, so... And then go back and do other things." But I do think this admixture is important because of the complexity of the job.

    2. PAPeter Attia1:00:42

       In that first term, what was the camaraderie like between parties? You, you hear stories of... I'm in the middle of, uh, reading a book about Abraham Lincoln right now, and it... Maybe these books somewhat romanticize it, but obviously there have been huge swings in sort of how partisan the country has been. But there are these periods of time in which politicians of opposite parties still socialized 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, 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"?

    3. BFDr. Bill Frist1:01:43

       Yeah. It, it's, it's really important. And like you, you don't wanna over-romanticize the past. And recent events, you're asking the same question, "Is that the way it's always been, or is this brand new?" And the first six years and the last six years were different for me. I served under two presidents, one a Democrat, President Clinton, and the other President Bush, or with them. And it wasn't because of them, but it was because of, in part, media, and because of the in- in part the internet, in part initially it was cable TV. As we had more of this sort of real time, nothing could be done behind closed doors. If I wanted to take a trip called a CODEL, 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, you know, New York Times, Wall Street Journal, anybody would come and say, "You're spending taxpayer dollars by having a vacation over in, you know, Southern Sudan." [chuckles]

    4. PAPeter Attia1:03:03

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

    5. BFDr. Bill Frist1:03:07

       Yeah. No, ex- exactly. But you know, 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, 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 [chuckles] sitting together. And then over that 12-year period, much, much less of that. And then it's gotten much, much worse since then. I, 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.

    6. PAPeter Attia1:03:47

       And really, the scrutiny of the media played a role in that. Of course, the, the, the, the critic will argue, well, isn't that the job of the media to bl- 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? H- how do we think about this?

    7. BFDr. Bill Frist1:04:11

       Well, we're seeing it play out, and I think you're exactly right. The, the transparency is critically important, and past politics is, 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, our democracy. I think what changed it all is that what we're seeing today more than e- even when I was there, but is the misinformation that campaigns. If the media, like on this whole thing of CODELs 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 b- you know, before Twitter and before Facebook and, and all. But if you put the information out there, 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 disappeared, and that's unhealthy. And there are ways that you can fix that. I won't jump ahead with that, but there are ways that you can fix that, and it, it does have to be fixed. And it comes back to this being a doctor, I think. The empathy

11. 1:05:30 – 1:15:15

    Bill’s time in the Senate and quick rise to Senate Majority Leader

    1. BFDr. Bill Frist1:05:30

       word really does come back to this connectedness. Doesn't mean you have to agree, but this connective seeing two sides of things, and there's just less empathy in the corporate structure of the United States Senate today.

    2. PAPeter Attia1:05:43

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

    3. BFDr. Bill Frist1:05:46

       Yeah. It's, it's, uh, interesting. I sat on the Banking Committee. Actually, I had been on the board of a bank ironically before. It's not the reason I went on it. But Pete Domenici was on it, and when I was choosing my committees... The way committees are chosen, you're... I was 100th in seniority, so I had 99 people [chuckles] above me.

    4. PAPeter Attia1:06:05

       Were you the only freshman senator elected in '94?

    5. BFDr. Bill Frist1:06:08

       No, there were others elected, but the ones, if you've served in public office before

    6. PAPeter Attia1:06:13

       Got it

    7. BFDr. Bill Frist1:06:13

       ... you get credit for it. If you've been a governor, you get credit for it.

    8. PAPeter Attia1:06:16

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

    9. BFDr. Bill Frist1:06:19

       Yeah. I mean, I thought I was okay being a heart surgeon and taking care of people and saving their lives. When I got up there, boy, they could care less, especially when it came to committee choice or it came to-

    10. PAPeter Attia1:06:28

        [chuckles]

    11. BFDr. Bill Frist1:06:28

        ... anything that had to do with appropriations or power, that sort of thing. But the committees I ended on were great committees. One was the Banking Committee, fascinating time and always a, a good committee. It has no power per se, but a really important committee in terms of constituents back at home. And the Health Committee or the Health Education Labor Pension Committee, which is health, and that it did include things like I chaired the subcommittee on disability policy. And, you know, for the whole United States of America, every law of the disability, uh, world had to come through that particular committee. And then went to Foreign Affairs with... about two years later and stayed on that throughout because I ha- had done so much travel to, to other countries doing medical work, and it, it fit there. But those were the ones in the first few years that, that I was on and learned a tremendous amount. And then in the last four to year six, I joined the Commerce Committee. And the Commerce Committee, that was the time there was, uh, telecommunication and all of the great reform that was going on then.

    12. PAPeter Attia1:07:30

        I've resisted asking you this question before 'cause I wanted to ask you for the first time during this discussion. How is it that someone so young and so junior in tenure can become the Senate majority leader at such an early time in their tenure? So I guess walk me through the late '90s. You're obviously going for 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, a relatively junior senator to being, you could argue, the second most powerful person in Washington after the president?

    13. BFDr. Bill Frist1:08:08

        Yeah. It's, it is an interesting sort of line narrative i-in large part because, uh, that was not my goal. And if you're gonna start with one hundredth in seniority and jump to number one in a period of six years, uh, that it just sounds crazy.

    14. PAPeter Attia1:08:24

        [chuckles]

    15. BFDr. Bill Frist1:08:24

        And it is crazy. And, and, and Lyndon Johnson did it, but he'd spent all those years over in the House of [chuckles] Representatives. But to, to come in-

    16. PAPeter Attia1:08:32

        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've been different had he not. But yeah.

    17. BFDr. Bill Frist1:08:48

        Yeah. But the sort of sequence of events was I won re-election. At the time, there, Bob Dole, who is, uh, just an iconic leader as well, and Trent Lott and, and others were sort of the... Trent Lott represented a younger generation, but all very senior to me, were sort of at it at each other and competitive and sort of the intrafamily politics and class office sort of stuff. And I didn't pay any attention to that really. What I was interested in, and I, I use 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 wanna affect a board, a nonprofit board or a for-profit board or the United States Senate, 100 people?" The best thing to do is to get involved in the determination of who's in the room and who is not. And therefore, in leadership, the sort of fourth or fifth position down, depending on how you look at it, in the Re- Republicans, say there are fi- 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 Thune. Maybe they would've ended up there, but maybe, probably for most of them, they would not. And so I ran for a leadership office then, and that leadership, I... Again, I did... This wasn't... I came there to do policy, to pass big stuff that would help people in health and welfare and lift them up in education. So I said, "Let's do that position for two years, and then I can come back and do policy the last four." And so that year, six years in, between sixth and eighth year, we did what you implied or you suggested earlier. I ran that group. I represented the United States Senate in every state. I had to raise money for the Senatorial Committee. But we won that year 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.

    18. PAPeter Attia1:11:09

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

    19. BFDr. Bill Frist1:11:11

        You know, it was, it was all sorts of, of macro everything coming in. But we won, and we won big. And so I... And I worked it hard. And again, I, as being a heart surgeon, you're not trained to do that sort of thing, but I traveled, and I recruited people, and I'd go to, uh, New York. I'd go to North Carolina. I'd go to Nebraska. I'd sit down with 10 people who wanted to run for the United States Senate. I'd spend hours with them. I'd talk to their families and their spouses and say yes and say, "This isn't gonna 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.

    20. PAPeter Attia1:11:50

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

    21. BFDr. Bill Frist1:11:56

        No, no, no, no. I, I... No, no, no. Not even-

    22. PAPeter Attia1:11:56

        No, you, you were going... You were in it to win it.

    23. BFDr. Bill Frist1:11:59

        Yeah. No. Well, no, the expectation was It's very unlikely to even break even. 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 minimum. [laughs] 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 just a doctor doing his best, you know, a good guy, can bring people together, can bring the Democrat, can bring the Republican together. But, you know, and by historical precedent, not, you know, nothing great. And 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 leader, I, again, I didn't want to be majority leader. It wasn't my goal. In fact, if you go to be in leadership, it's hard to do big policy. It's hard to do the sort of things I ended up doing, HIV, AIDS, PEPFAR, these huge things that affect millions of people if you're the leader. And you look at what McConnell, if you're, or whoever's the leadership, Schumer and McConnell today and whoever it will be, you know, as people listen to this in the future, they don't have time to do the legislation or the policy. They're out there managing, they're herding these cats being the leader. So I didn't want to do that. I only had 12... I only had four years to go. I didn't want to spend four years herding cats. But when it came down to the election, there were five people who wanted to be majority leader, and all of them, to be majority leader, you had to have 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 get together with other people. And I wasn't a part of any of that. But then it got down to where nobody had the votes. And people came to me, and I had a group of people because I'd come off these Senate races with credentials. They said, "Well, what about you?" And then all of a sudden, all these, all four of the other people came to me and said, "If you will do it," I c- they said, "I can't win. And if you are interested, we want you to be majority leader." So I haven't really told that story publicly, but I think it is important for people to... It humanizes the place. You know, this is no different than elections in life, and things are fair, and things are unfair, and luck is a part of it. But that's it. That's the story. Did not have the credentials, didn't want it, did want the two-year job so I could go back to policy. But the two-year job did well but got lucky, really lucky, and won. And then at the end of the day, because, in part because of this doctor thing, they also saw me as somebody that is non-threatening. They said, "If this guy comes in, uh, I won't stay here forever," they would say to themselves. This is my job. This is my pinnacle in life. And my pinnacle in life is doing heart transplants, you know, right here, out the window, going to Vanderbilt and, 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."

    24. PAPeter Attia1:15:13

        As you alluded to earlier, these

12. 1:15:15 – 1:19:45

    The lifesaving impact of the President's Emergency Plan for AIDS Relief (PEPFAR) under George W. Bush

    1. PAPeter Attia1:15:15

       next four years, while you're Senate Majority Leader, are quite busy, and potentially one of the signature things you're a part of is PEPFAR, which you've alluded to. Now, I've always found it interesting how little Americans understand PEPFAR, and yet, 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 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?

    2. BFDr. Bill Frist1:15:53

       I partially agree. Uh, you know, PEPFAR-

    3. PAPeter Attia1:15:56

       Let's start with telling people what it is. Yeah, yeah, yeah. Let's-

    4. BFDr. Bill Frist1:15:58

       But we're talking about HIV/AIDS, and it makes sense, being the only doctor in the Senate, that people would, 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, um, a province called the Lui 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, uh, 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 [laughs] came, and President Bush, uh, this is 2000, had never been to Africa. That maybe he'd been one time when his dad was president for a, a night. In conversations with him and other people, Tony Fauci, who everybody's heard a lot about today, was a huge part of it. I'd bring pictures back of people dying of HIV/AIDS. But the story at that time was that three million people, three million were dying every single year because of a little virus that in 1980, in 1981, we didn't know what it was. We had never even seen it in the United States. But with three 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, of a disease. And so President Bush basically listened to the stories, focused on it, sent Tony Fauci down to Africa. You know, "Is this something we can do something about?" He came back in a surprise way at the State of the Union message, 2003, when I was majority leader. I knew it, and probably five or six other people knew it. Basically said, "I'm gonna make the single largest commitment to a single disease that's ever been made by a president of the United States." This little cagey virus, HIV/AIDS. At the time, Republicans and faith-based people, you know, thought it was a disease of gays and was bad, and the Jesse Helms of the world basically said it was a, you know, a call from God and punishment and all. The left wasn't doing anything about it, uh, but they talked about it, but nobody would step up. So President Bush, I wrote the, 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, twenty million people are alive today because of that five-page bill that surprised everybody coming out of this president.

    5. PAPeter Attia1:18:39

       And it's no small figure. I mean, we're talking... You said, you know, Clinton put a hundred million into this. I mean, your bill put sixty billion dollars into this, if I'm not mistaken. Is that right?

    6. BFDr. Bill Frist1:18:49

       Over time, we were spending about two hundred million a year. And again, President Clinton was right on all the issues. Uh, and later, after he left office, as you know, made a big issue about it and still has, has done unbelievable things through the Clinton Foundation for it. But at the time, there were just so many other things going on. So we're spending about two hundred million, and then that first year with President Bush that we got it through, the first year, three billion dollars, and then three billion dollars a year for five years, and then over time is the sixty-five billion dollars because subsequent presidents have continued with that program coming forward. But the interesting thing is it came from way out to the right, and it came from a people who brought the left and the right together in a bipartisan way. And when I brought it to the floor of the Senate, you know, it was close, but it was bipartisan, and it passed, and, and when the House passed it. So it will be legacy and legacy changing. And then the spinoffs from it, all that money is spent. It's not just on

13. 1:19:45 – 1:30:00

    How Bill reversed course on his view of the value and morality of stem cell research

    1. BFDr. Bill Frist1:19:45

       HIV/AIDS, it's on tuberculosis, malaria, infrastructure, surveillance, putting clinics in, in cities and in communities and villages and towns all over the world, not just Africa, but Russia, China, a- and around the world.

    2. PAPeter Attia1:19:58

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

    3. BFDr. Bill Frist1:20:20

       Yeah, you know, it's interesting to sort of go through what stem cell research is because the changing of the minds or the switching of positions or sort of the role of a senator is one that's kind of worth going through. So I, I had come to this Senate as a physician. I know brain death well because all my donor patients, I'm involved in all of those. I am in immunology. I-- when I came to the Senate, I was in, in... You know, did things like disability policy and health. So people came to me on this particular issue coming in. And there was an amendment back in 1996 which basically banned federal funding of stems, embryonic stem cell research, not a- 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 and it could become a liver or a heart or a, you know, pancreas. You could kinda channel it in those directions. And the second thing, it was like a... Back in those days, we'd say it's like a copying machine. You can make unlimited copies of it. No other cell ever in the history of man had 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, neurodegen-degenerative disease, the hope for everybody, including me as a scientist who kinda 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, or local monies? So the issue is all what happens at the federal level. So you had that amendment, and then President Bush came out in 2001, and he said, "We're gonna fund embryonic stem cells for the first time, but we're only gonna do very little. We're gonna 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 'em is by creating an embryo and then destroying the embryo. So you can see real quickly where this is going. You got pro-life, pro-choice, fifty-fifty in America. Pro-life people said that the embryo has the full genetic code. It is... All you gotta do is nourish it. It is a human. It may be early on, but it's in the first stage of development. So the ethical issues there were Americans, uh, believe that, uh, or half of America believes it has a sort of moral value of some sort. Do you allow embryo mills to be created? And so that's where the ethical issue, a fascinating issue. So Bush said, "No, we can't do that. Let's, 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 it to 78 lines. So I endorsed that. And about two months before that, and this was all written up in the Wall Street Journal and 'cause it was all new science and political, I'd written, gone to the floor of the Senate and said, "I think that here are my 10 principles. Let's put 'em forward and engage federal funding. State funding c- is okay, and local funding is okay. That's outside. But for federal funding, let's limit it like Bush limited l- he limited to 78 cell lines." I said, "Instead of doing that, let's sort of stay with the times and use these blastocysts or these little embryos that are used in fertility clinics that are otherwise gonna be thrown away, that are discarded."

    4. PAPeter Attia1:24:04

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

    5. BFDr. Bill Frist1:24:09

       Exactly. You create five of them, you implant a couple, the other three are thrown away, discarded. So my argument in my ten principles that I went to the floor in two thousand was that use those. So Bush came out with something different. He limited to seventy-eight cell lines. So I endorsed that because at least we're, we're getting federal funding of stem cells. And then we jump four years later, and this is what's really interesting, uh, to me, and this is really important, I think, for our senators today. Science changes over time. You learn things. There are better techniques. There's evolution of knowledge. You-- clinical trials prove things. And it got to be four years later that it was clear those seventy-eight cell lines didn't work. They were contaminated by mouse cells. Only about twenty-two 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 ten principles back out, again, went back to the floor of the Senate, put those ten principles out there, and-- but the reason it became such a big politicized issue is that President Bush, uh, did not agree with me and, and, and the majority of the Senate and the majority of the House. We passed in two thousand and five a bill called the, I think it was the Stem Cell Research En-Enhancement Act. It passed. It says you could, you could use these blastocysts. An ethical construct was set up. You got consent set up. And then that bill passed overwhelmingly bipartisan, but it was vetoed by, by President Bush. And so then people said that Frist and Bush are in totally different areas. But from the day one, the embryonic stem cells, to me, have been a heart transplant surgeon, were the most exciting science that had come by in ten years. But when this whole ethical issue came up, 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 four hundred dollars to create embryos to have them destroyed, and there was no mechanism, discipline mechanism around that, that we had to create that. And ultimately, it got created, and now we jump, you know, ten, fifteen years later, the same principles that I had put in in two thousand and two thousand and five are the ones out there. And that's where that research has gone. And in retrospect, it, it's probably been pretty good in the sense that the stem cells eventually are gonna live up to the promise. But we're seventeen years later, and adult stem cells are used in bone marrow and, 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, you know, seventeen years later, and some good things are happening, but still there's no embryonic stem cells being used to treat the Alzheimer's and Parkinson's.

    6. PAPeter Attia1:27:02

       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 thirty-two times, thirty-two doublings, and become cardiac myocytes, and this subset of you are gonna go on to develop Purkinje fibers, and this set of you will not"? I mean, it's, it's-- it-- we j- we're still so far from cracking the code of what the instruction set looks like to the stem cell. So it's-- this is step one of ten, basically, in, in terms of that.

    7. BFDr. Bill Frist1:27:36

       But it's hard to tell people that. And as a policymaker, you have to make the decision. You have to set up the construct, or you're not gonna 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 two thousands, within two years, your Parkinson's could be-- or your, 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, of life. And that's the tough job of a policymaker. You got, you know, a hundred regular people there who, you know, some are smart, some are not, that are, you know, maybe not perfectly representative of people, but they've got to make these, uh, decisions. So, you know, it's the sort of thing that, you know, at the end of the day, we increase federal funding for stem cells. Constructs were put around it. Imperfect. His approach was different than mine. People, you know, 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, well, pretty, pretty well and, and we learned a lot, and it comes back to science a lot and these fields that, uh, 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, all of which we can-- 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, to Main Street and get the right ethical constructs? And that's what our policy-- I'm not a policymaker now in that sense, but that's what these people in Washington do. That's what we hire them to do, and that's what we need to hold them accountable, and they need to do it in the best way they can at a point, a point in time. So things are gonna shift with time. In that particular one, I-- luckily, I did the same ten principles in two thousand as I did in two thousand and five when I passed the bill. It got vetoed, by the way, so I lost. But ultimately, back under President Obama, the same bill was taken out and passed.

    8. PAPeter Attia1:29:42

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

    9. BFDr. Bill Frist1:29:53

       Well, yeah, it's a good point because you-- if you can have a majority of the votes for it or a super majority, but you have to have

14. 1:30:00 – 1:49:45

    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. BFDr. Bill Frist1:30:00

       two-thirds or three-fourths come back. So if he vetoes, you have to take a whole another vote and then override that veto. So he or she has that intervening time to put, you know, pressure on people and, and change that.

    2. PAPeter Attia1:30:11

       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, 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 Reitz. And it's an interesting story because again, here's Bruce Reitz. 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, the warm, fuzzy... But he was like the most soft-spoken human alive. Like you, 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, should be withdrawn. So of course, as a transplant surgeon, you are intimately familiar with what the criteria are for brain death, what makes a donor, what does not make a donor, et cetera. And so again, here you are now Senate Majority Leader, and a very public case comes up, this case of this young woman, Terri Schiavo. And I guess just for folks who don't remember this, this-- and you can correct me on some of the details, but my recollection, 'cause 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, I believe her potassium got as low as two to two point five milliequivalents, which not surprisingly put her into an immediate cardiac arrhythmia and arrest. By the time the paramedics arrive and resuscitate her, because she's so young and healthy, they can get her heart beating again, but her brain has been without oxygen for minutes. No one really knows. This was in nineteen ninety, 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, you know, she's gonna be in a persistent vegetative state for the rest of her life. This is not what her wishes were. She's being fed through a tube. The parents feel otherwise, and it just keeps escalating its way through courts, and it gets higher and higher and higher and higher. I don't remember exactly how it got to the point where Congress was now being asked to weigh in, but may-maybe you can pick up the story of how this basically rose to a national story and, and frankly, even potentially involved the US Congress.

    3. BFDr. Bill Frist1:33:23

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

    4. PAPeter Attia1:33:36

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

    5. BFDr. Bill Frist1:33:38

       But no, it is a fascinating case and it, 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, on a, a ventilator for a long period of time. But increasingly it's gonna get more complex 'cause technology and science is gonna give us these tools to use. So lots of lessons in, so it is worth going through it. So you're exactly right. Nineteen ninety, Terri Schiavo collapsed, hypokalemia for just a persistent vegetative state is a medical term. It's an important term here because the law uses it. But for people who are, who are listening to us, you know, you're on a ventilator and you can move and open your eyes, but it's just you have to be supported overall with both feeding tube as well as a ventilator. And Michael, her husband, you know, did everything, at least in my review at the time. He took her to UCLA, took her to multiple centers and, and for rehabilitation. And then three years later in nineteen ninety-three, he'd given up, uh, basically, and I don't know. I wouldn't involve the family then. I-- this is ten years later that I got involved. And but the, the issue was exactly as you described, that all of Terri's blood relatives, the mother, the father, the brother, the sister, objected to Michael putting her on a DNR or removing the tube. A do not resuscitate or removing the tube. So you had this dichotomy of walking in the room, just like you said Bruce did. You had on one side, one person who by the law says if she's in a persistent vegetative state, the husband can make the decision. On the other side of the room, you had all the mother and father who raised her, who cared for her, 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, and Michael disagreed on their impression. They also disagreed because she had, and this is what the implication is, everybody listened to sort of this part. She had nothing written down. She had no living will, no advanced directive. And therefore, you had the parents and everybody says, "Well, of course, she's a devout Catholic. She, she values life." And you had the four of them saying, you know, "We'll support her. We'll take care of-- financially, we'll take care of it." And then you had Michael, who by the law would have that responsibility of saying DNR or, or not

    6. PAPeter Attia1:36:17

       I just wanna 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, while you don't have to worry about it, you go through this exercise. I mean, my wife and I did this 12 years ago. Sat there in a lawyer's office and spent an hour going through what we wanted and what we didn't want, down to the levels of detail that is comical, right? Now, not everybody has the luxury. They might not have the medical. My wife's a nurse, so, you know, we could talk about it through, "Well, this is-- I, I would tolerate this many line changes or this many weeks of a trach and this feeding tube," blah, blah, blah, blah, blah. But it is very important, I think, to, 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.

    7. BFDr. Bill Frist1:37:26

       And it's ha- it's hard. You just have to do it. People don't like to think about death or where they're gonna be buried [chuckles] or wills. This is one that out of respect for your, for your loved ones, and it plays out here and, and, and I'll mention again 'cause I'll, I'll come back to it because it, it had real implications. But they had nothing. The interpretation of one set of relatives and then the husband were very different. So jump ahead seven years. Her feeding tube was taken out. Then a court, these courts, as you said, kind of came in and they replaced it. At the time then, thirty-three 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, you know, complicates things a little bit because she's in this either minimally conscious state or persistent vegetative state. So in two thousand and three, the court ordered five doctors, these are state courts, ordered five doctors to, to test Terri. Two appointed by Michael, the husband, and two appointed by the, um, family, and then one appointed by the judge. Three to two, they said she was in a persistent vegetative state, and it would be okay to withdraw therapy, take the tube out, take her off the ventilator. The two who voted against that said, "No, she's in a minimally conscious state and can ha- can recover." So she stayed alive for about six days, and during this six days, it became this huge global issue. It went to the state of Florida. The state, their equivalent of their House and Senate, the legislators got together and actually passed a law in that six-day period that gave governor, Governor Bush at that time, the order to put the feeding tube back in. All this is over a six-day period. The Supreme Court there struck that down. And again, this is kind of the politics, and you say, "Oh, gosh." As you said, the Bruce Reitz 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 politics. You had Pope John Paul made a statement [chuckles] on behalf of the family and the sanctity of life, and that they would support her, and that was their belief. The brother, the sister, the parents said, keep her alive, and that they would support it financially, and somebody gave two million dollars or said they would give two million to support her. So that's that. So of course, coming back, being the only doctor in the Senate, and maybe it was one more at the time, and knowing brain death, I was involved in all those discussions and, and when I was at Stanford, the ethical issues, the disability policy, the only physician. So I jumped-- didn't want to do it 'cause 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. Uh, and a- again, it was a long time ago at, at this point, two thousand and three. 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 kinda what I-- where I came down to. And the question is, which part of the family do you listen to? The one that the law would give it to, ultimately, it would be the husband, or all of the siblings and the loved ones and the people who had lived with her and taken care of her in large, large, uh, part. And i- it's a little bit like, coming back to the transplant world, if I walked into a room to remove a donor heart to bring it back to Vanderbilt to transplant it, and I walked in the room, and the patient was there in the operating room, and there was a spouse who said, "No." He said, "Take the heart. It's okay." But the rest of the family said, "No, we don't want you to desecrate, you know, the body of our loved ones and take the heart," even though the law would say I could do it, you know, under these donor laws that we have, I wouldn't do it. Of course, I wouldn't do it. I wouldn't. It's t-- you know, to me, it's just not the right thing to do. So what did I do?

    8. PAPeter Attia1:41:30

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

    9. BFDr. Bill Frist1:41:42

       It's fairly fair-- As you can imagine, it's fairly co-- it's rare, but it's common. And so no, I did not. I would not take off in the airplane tonight if I knew, talking to the donor counselors up there, that the family disagreed, although legally it said... So I avoided it totally. And others may have, have done it, but I would not do it. But yes, it's not that... You know, as you can imagine, you get six members of a family, and they all disagree about something unless you have a Bruce Reitz walk in. You've, you've described that well. So the first thing I go, Pastor, 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 minimally conscious state.

    10. PAPeter Attia1:42:19

        What is the difference there? I mean, I wanna just kinda make sure some people understand what we're talking about. She has some brain stem 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?

    11. BFDr. Bill Frist1:42:35

        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, after she died, and she did have very, very serious disease. But it's a tough diagnosis, and that's the world we live in.

    12. PAPeter Attia1:42:58

        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 postmortem?

    13. BFDr. Bill Frist1:43:07

        Yeah, after. See, yeah, that was after. That was six months later 'cause then it all surged up again, as you can imagine. So talked to the neurologist. He just happened to be the last neurologist. I personally, as majority leader, met with the brother. It was, 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, just 'cause 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, uh, so I checked with the Senate leadership. Harry Reid was the Democrat at the time, became bipartisan. The House led on a bill, and I'll come back to what the bill was, and we had a bill, and it was bipartisan. It was ov- it was supported unanimously in the United States Senate, overwhelming majority, both parties in the, uh, House of Representatives. And 15 neurologists had signed an affidavit and all of that that said that she needed an independent current evaluation, that she hadn't been evaluated recently. So really controversial, even among my staff. They said, "What in the world are we doing?" And I said, "I know, you know, but this has come to us, and it's at an issue that it cannot be resolved." And it... 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, that you do. Bill passed unanimously in the Senate. In the House, it, I think it was like 210 to 50-something, bipartisan. What it did, the bill itself guaranteed a process and not an outcome, and so it basically didn't say keep her alive. It basically said she needs an exam that is truly independent, not with courts and not done by politicians. And once that exam is done, if she's in a persistent vegetative state, then remove the tube if that's what the husband wanted, and if not, the family should be listened to, the extended family should be listened to. So the outcome, it passed the United States Senate, it went to the federal courts, they denied the petition, and the feeding tube was removed, and she was allowed to die. So that's the story. So it's r- it's an interesting one. And, and on reflection, you know, again, publicly, I don't go through this, uh, and I've written some about it because I, I've written a lot about brain death issues and persistent vegetative state. But as a policymaker, it, it-- the story captures this sometimes necessary conflict and th- 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, 'cause a lot of people say, "That's gotta be the biggest mistake you did in 12 years." And I say, I kind of just avoid it and move on. But in, in retrospect, the fact that it had 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, life, liberty, pursuit of happiness, the oath that all those 62 lawyers and everybody take in the Senate. But I'd also taken this other oath, this Hippocratic oath, to protect life and to, to do no harm. And when it's, 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, uh, what I would interpret as life. Others may not. And this has gotta be exceptional and rare, and it has been in retrospect, and those kinda cases haven't made it back to, to Congress. And these decisions clearly, clearly, clearly are best made locally. The other challenge, and I'll close on that, is the, um... Politics made it worse because you had the Chris Matthews of the world [chuckles] who would go out every night and, you know, big sort of Democrat and sort of after people, and he would, he would basically say, "Here you have Senator Frist, Frist playing doctor in the United States Senate. You know, he's one of those northern Republicans." And then the Republicans would shoot back from the House and say, "Oh, this is a great case 'cause it shows right to life." What I did and what I, I tried to do w- with these, and it's hard to do, is to separate the politics from the policy, to separate the politics from the science. And, uh, it, it shows, this case shows th- 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.

    14. PAPeter Attia1:47:59

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

    15. BFDr. Bill Frist1:48:55

        Yeah. And, you know, and, you know, issues, all issues, and even with impeachment back in the past, people have a hard time understanding that politics is, is a part of our democracy [chuckles] . And you wish, and with things so partisan, everybody wished, not everybody, but so many of us wish you could push this extreme partisanship out of it. But thing, even things like impeachment, there's a political nature to it. It was intended to have this political thing. And politics and policy can't be separated totally, and that's why I come back to this tension that has to be there, 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 'cause laws are imperfect a- as well. And that's the sort of representatives that I think we, we do, we need to aspire to

15. 1:49:45 – 1:56:45

    Remembering the events of September 11th from Bill’s perspective in the Senate

    1. BFDr. Bill Frist1:49:45

       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 s- state assemblies.

    2. PAPeter Attia1:49:56

       It's so hard to believe that we are now in the 20th year since 9/11. I wanna go back to that Tuesday morning for you 'cause 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?

    3. BFDr. Bill Frist1:50:25

       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. You're a United States senator. The security at that time rest 100% with the president and a co-equal branch of government, the Congress, and with inadequate information, no information having to make decisions there. So the fright of it, my first thoughts when, when it hit, I was out in front of the Capitol and over at, uh, another senator's office when the first plane hit, and I fly and fly a lot, and it'd be really unusual for somebody to hit a building, World Trade Center, but it could be done or it could be a suicide mission.

    4. PAPeter Attia1:51:23

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

    5. BFDr. Bill Frist1:51:38

       No, not at first. I was in an adjacent room. I was out- outside of the Capitol in an adjacent room, and somebody just said, you know, "Should you stop your meeting because the plane hit the Cap..." Same thing as, as what you said. Then when we figured out that it was a- 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, at that time doing the Senatorial Committee. So at that level, you get briefings beyond what other senators get. And then when you're majority leader, you get even 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 to, that you'd think about. But I knew the capacity that this wasn't just like a small thing. This was really gonna reflect the world. And then when there were two, always when there are two in life, there, there's gonna be a third in, 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, 'cause my kids were in school over in Washington, over near where the vice president lives, and it's near the cathedral. And I knew if they're going after us, they're going after Pentagon, they're gonna hit any sort of symbolic sites, and that they went to school right there. So of course, concerned and worried about th- 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, uh, senators, a few House members, a few Supreme Court justices, uh, 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. And 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 gonna ensue over the next 12 hours, this is different than anything in the, at the operating room, at the table. And there you're doing life and death things every day. This was different.

    6. PAPeter Attia1:53:53

       Do you recall, like, what you went through over the next two or three days? 'Cause I, I, I mean, I think back to it and I've, I've been thinking a lot about as we approach the 20-year anniversary, the stuff I wanna talk about with my daughter, who obviously was born after. And in some ways, it feels like it was yesterday 'cause 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 that evening 'cause 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, 100x. But do you also have sort of pockets of that period of time that are almost a blur, or does everything still sort of fit, you know, nice and neatly and linearly into your recollection of the weeks that unfolded from that?

    7. BFDr. Bill Frist1:54:54

       Yeah. No, it's a, it's an interesting question. I think the difference was that We knew we had to act. And the first thing that we needed to do quickly, we didn't know if this was a single actor, 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, was pretty quick, we had to pretty much assume that we were gonna all be taken out. And by us, it's not us, we don't matter, but it's the United States of America. So you go after New York, you go after Washington, D.C., you destroy the Congress, you 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, 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, of the Capitol, and this is the sort of thing that does bring Democrat and Republicans together, I mean, really closely together, and nothing else sort of matters. We're talking about the safety and security of our country and maybe, uh, existentially the future of our country. And so we went out, and I remember obviously the, the people you think are, are... who are there, the leadership was there, of course, and the, the people were there, but the John Lewis's of the world, you know, spoke and we sh- displayed to the world that, that you can try to take us out, but you can't take us out. And I think that was really important. We did that after the anthrax attacks. Other attacks, we sort of did that. But I think it's really important to make that statement to the world to, to stand strong. And then it was, it was, it was... But once we knew we could reconstitute government if something worse ha- happened, it really was just sort of systematic of up and run. This is how much intelligence we have, making decisions,

16. 1:56:45 – 2:06:45

    The coronavirus pandemic: Bill’s accurate 2005 prediction, and a discussion about future preparedness

    1. BFDr. Bill Frist1:56:45

       should we hit? How fast we should hit? Should we hit at all coming back? If we hit, what's gonna come at us next? So it was a busy time. And then I had family, as I said, that, that was always in the back of my mind, just being in Washington, D.C.

    2. PAPeter Attia1:56:59

       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, uh, I ca- 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?

    3. BFDr. Bill Frist1:57:49

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

    4. PAPeter Attia1:59:47

       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 gonna be complete and total social chaos. There's gonna be supply chain disruption, boom, boom, boom, boom, boom, and a pandemic preparedness strategy should include stockpiles of antiviral medications, all of these other things. It's easy to blame one party or the other, but the reality of it is no administration's really ever taken that seriously, have they?

    5. BFDr. Bill Frist2:00:41

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

    6. PAPeter Attia2:01:39

       And just to be clear, you thought it was inevitable just from these factors, not necessarily even bioterrorism. I mean, you were thinking-

    7. BFDr. Bill Frist2:01:47

       No

    8. PAPeter Attia2:01:47

       ... that would be another potential way, but it was-

    9. BFDr. Bill Frist2:01:50

       Yeah.

    10. PAPeter Attia2:01:50

        Yeah. Okay.

    11. BFDr. Bill Frist2:01:50

        Yeah. And, and I used the bioterrorism a little bit because I talk 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-twelve-foot room with, you know, with simple things. And so the bioterrorism at the time, because of, of, you know, nine eleven and all the things that, that had gone on, uh, it was clear we needed to worry about that, especially with smallpox, because Russia had a supply of smallpox they could use. But no, this was outside of that. This was sort of coupled with that because the same things that you need are the communications, the infrastructure, the stockpiling, the virology, the research and development, the antiviral agents, the manufacturing capacity, all the things. These are all the things that, as I say them now, people are saying, "Oh, yeah, check, check, check. That's, that's with COVID." [chuckles] And the point is, and I called it a Manhattan Project in each of these speeches, and, and as I said on the floor of the United States Senate, I left the Senate the next year, and work has been done and people have tried to do pieces of it, but nobody has really si- stayed on it. But the six proposals I testified before Lamar Alexander's committee about the next pandemic a month or two, about two to three months ago, because right now is the time we have to talk about the next pandemic. There will be another pandemic, and will we be prepared? And we all know, and especially political people, that, you know, it's only the snake that's at your foot that you're scared of. [chuckles] Once the snake goes off in the, in the, in the trees, you just lose that sense of sorta urgency there. So from the scientific standpoint, I mean, I wasn't any great-- I mean, we, we say this like I c- could see it. I wrote it down, and I wrote what we should do, and what we should do, we didn't do, and therefore it's, you know, 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, you know, I don't think that'd be the case, but it's gonna take, you know, a, a constituent and people saying, "This is an existential threat." This, you know, this COVID thing is, is not a deadly virus. I mean, it did. I say that, but-

    12. PAPeter Attia2:04:03

        Well, I, I mean, that's, that's, 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-I or MERS. And there's a sweet spot. Obviously, if a virus is so deadly that it basically knocks transmi-- like if it's an Ebola virus, in many ways, those are less threatening because they kill people so quickly. But, uh, there's an inverted U shape of lethality, and SARS-CoV-2 is actually quite far to one side, which is it's so non-lethal 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, 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 twenty twenty-one to really say, "Okay, well, what-- w- 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?"

    13. BFDr. Bill Frist2:05:19

        Yeah. Exactly, and, and it's funny, with, with Lamar's committee, he ran the health committee, was chair of it, of the health committee, and he took a lot of heat. I listened to it. I love not being there [chuckles] because I can sit there, listen 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, you know, of course we do, and we're doing everything we can, but look what history has led us to." And, you know, there are clearly things to do, but how do you get people to stay on it and understand? And it-- there's simple things, infrastructure. Right now, the, you know, things like vaccine distribution, which has been so challenging, you know, that's the sort of thing. And, and public health infrastructure locally, there are fewer public health people on full-time payroll in our communities today, wherever you are right now, than there were eight years ago. Public health people. It's-- public health has been the, the stepchild of health and welfare and healing. That is, it's inverted now, and people appreciate it, but are we gonna 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, 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

17. 2:06:45 – 2:12:45

    The divided state of US politics, and how we can come together

    1. BFDr. Bill Frist2:06:45

       getting other experiences from life and having them participate in supporting them in those positions.

    2. PAPeter Attia2:06:51

       So I wanna kinda 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 the, all these other things that, that we could... Ev-everybody can rattle off all the things that could be broken today. How optimistic are you that if we can both agree that where things are today is suboptimal, it's gonna get better?

    3. BFDr. Bill Frist2:07:49

       Yeah, you know, I, I, um... On my podcast, I ask people the sort of the optimism question a, a lot, and 90 out of 100 say they're optimistic about things. That's really interesting and, and so I'm, I'm slowly gonna answer it because I think you have to be really, really careful. On the... Uh, first of all, I, I am optimistic, and again, it's my nature, and I tend to get involved in things that seem to be challenging, and I, 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 gonna be really difficult and probably not get a lot better and may get worse. I think if you look at structures that are contributing to it, we're gonna 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, in discussions with, with people in the sorta Facebook direct world and the Amazon world and the Google world and the, the, the Netflix world. It's gonna take a little bit further, but I think we're gonna get better there. When we get better, that will put us in much better standing, 'cause if we're still on the curve of getting worse, and it may get worse another... You know, this world populism, it may get a, a little bit worse, but it will get better, and I'm, I'm optimistic about that. Leadership I think is gonna take a while. I'll, I'll tell you just a real quick story. When I, when I was in the Senate... Things are partisan. Again, we don't wanna idealize the past. But President Bush... And President Clinton did not d-do this, uh, 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, two Republicans, two Democrats, and from the House leadership and, and every Friday do breakfast with them quietly, no press, right off the Oval Office, and it was uncomfortable. You'd have the... I shouldn't mention any of the names, but you'd have the people who are the leaders around the table, and, you know, people like Nancy Pelosi and President Bush sitting side by side for breakfast for an hour [chuckles] . There's a little bit of a tension there. But I... And this was before the Iraq War and things got really complicated in, in so many ways, but, but for that period of time, things seemed to be so much better. Uh, really uncomfortable, and people... I don't know if people have talked about that either. But what... I, I, I say that and 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, of a Chuck Schumer and, and Mitch McConnell, you know, it's too ingrained there. But at that level, you pull 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-elect, soon to be President Biden out of it. Uh, 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, and the minority leader and, uh, and the speaker and the Democratic leaders in the, in the House, and that's not that hard. I mean, that kind of makes it sound simple to do. But, uh, sort of my experience a-and my thoughts, it could be as easy as that to begin to turn the tide, and I think we'll, we'll see that. I don't know if it'll be in the short term or long term or how long people will be around, but it, it takes that sort of courage to do it, to say, "I would... You know, I'm willing to sacrifice a second term," or something like that.

    4. PAPeter Attia2:11:59

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

    5. BFDr. Bill Frist2:12:03

       Yeah, it is, but, uh, you know, it's gotten to the point that, you know, how you elect somebody who really will do that from a very partisan group, it's makes it hard, but it's doable, and we're talking about regular people and, and, and people who, you know, can be reasonable and not always. It depends on the individual. But for those two reasons, I, I'm optimistic 'cause I think it can be done. I think it, it probably will be done, but I... And it can be done pretty quickly, I think. There's a real call from people, um, uh, for the sort of bringing people together. Doesn't mean sacrifice your principles, and 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,

18. 2:12:45 – 2:23:50

    How experience in medicine and politics is shaping Bill’s current endeavors in business, reforming education, palliative care, and more (2:12:45)

    1. BFDr. Bill Frist2:12:45

       as we did sort of more in my first term than in my second term in the Senate, sort of shaking hands after you have a big debate on the floor of the Senate.

    2. PAPeter Attia2:12:52

       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, you're doing venture capital. You're on the board of for-profits, not-for-profits. You're a part of the Bipartisan Policy Center, which is an organization I'm quite familiar with and, 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?

    3. BFDr. Bill Frist2:13:44

       Yeah, that's a great question because people th-look... It's a little bit like they look at you probably if you look at your past. [chuckles] They, you know, you've done different things, and you've tried different things, and is there any sort of narrative or thematic that sort of goes through that? And for me, it goes back, I'm sure, to this whole image of healing and health and hope and all, 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 in the transplant world, that was ten years learning and ten years delivering, and then ten years in-- or 12 years in politics, and then ten years in sort of the private equity world and, and, and then the last five years in, 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, "Twelve years in, 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? And again, this is thinking big, and it's not the sort of thing you tell anybody at the time. What would it be? And, you know, based on 20 trips to Africa and the global experience and all, and HIV/AIDS globally, and I came back to one thing, and it was K through 12 education, and globally, probably K through 12 education for girls. And if you're gonna spend, you know, a increment of time with my experiences, where would it be? So what I did is started a foundation. It's called State Collaborative on Reform of Education. It's by far the biggest in the state now. I started it, but got really smart people and good people, dedicated people to run it. And, uh, with that, it has had an impact where Tennessee has, for the last ten years, shown dramatic, dramatic improvement in K through 12 education and been recognized as such. So that is, is a little bit out of healthcare, but the nexus between health and education is so real. You know, the, the health feeding into being better educated, and the more educated sort of the better health. It just feeds together, and I, I see it, and the, you know, the, the data is, is, 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, you know, all of that. And so I, I start around companies-- I start companies and support companies that have a mission of taking people, usually vulnerable populations, and lifting them up. And the one that I'll just mention, because you asked for one, is one that kinda comes back to the things we've talked about, is palliative healthcare. 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, you know, 50 years, is really good. But in this world of chronic disease, where people are, are living, and as you described so well in, in your talks, you, you push that downslope on the chronic disease and the aging out as far as you can, but at some point you come to those graphs that you, you draw, [chuckles] and you're gonna bring things to a close, and it's chronic disease. So think of it that last year of life, that last eight months of life, and it's called palliative healthcare. 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 healthcare. But if you live 30 miles away or 50 miles away or 100 miles away, you can't, and you're sitting there with a chronic disease. You're going downhill. Your family, if you have family local, they 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, with, uh, this full circle sort of thing. It started with when I mentioned that I had hundreds of people being referred to me back in those early transplant years, right over here at Vanderbilt. They were coming in, but I could only transplant one every four or five days. I didn't have enough donor hearts. So I had 50 or 60 people coming in who were gonna die within six months, flying in, coming in, saying, "We need a transplant." And I'd say, "I don't have enough donor hearts." And so I had to learn how to take care of them, prolong their life, and getting the stuff right, the nutrition right, the exercise right, the mental health, the spiritual health right. All of a sudden, they started living not just six months. You know, they wouldn't come here if doctor hadn't told them it was gonna be six months, but they lived eight months, nine months, 12 months. So seeing that, and then I lost my mind and went to the Senate, and then I got out of the Senate, I came back, and we're still in the same place. Nobody had developed a palliative healthcare 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, and, and sort of general acute care, medical care a-as well. And so that's a sort of a good example of the sort of companies that, that I believe in. It ties things together. There are needs that are out there, and there are lots of other areas, you know, 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 anyhow, 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, to determine inflammation and, and then developing a new drug like cyclosporine, which revolutionizes that field. It's doing it in the business world where you have access to capital, you can move fast, uh, you're not slowed down by government. So it's, uh, pretty, pretty exciting.

    4. PAPeter Attia2:20:11

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

    5. BFDr. Bill Frist2:20:39

       [laughs] Yeah, I'm just fine. Yeah.

    6. PAPeter Attia2:20:42

       [laughs] No, it's been a pleasure speaking with you today, and I, uh, thank- thanks for all your service.

    7. BFDr. Bill Frist2:20:48

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

    8. PAPeter Attia2:21:02

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Episode duration: 2:23:50