Do Our Politics Need a Doctor?

Last week on Freakonomics, M.D.: we talked about how politics impacts our health and the care we receive. We heard about a study that found that doctors’ political leanings may influence the kind of care they provide to patients.

Eitan HERSH: We don’t think there’s a lot of political evangelizing happening in an exam room. But when you’re asked about something like marijuana or reproductive health, we think there might be some ideological or partisan biases.

And how salient this question is in the age of Covid-19.

Michael BARNETT: We’ve never really seen political divisions on things quite as basic as this before.

And while last week I mostly talked about how doctors’ political beliefs might affect how they treat you, I also started to wonder about the other side of that question: For doctors, does their profession — and everything that means, years of training and being with people when they’re at their most vulnerable — influence their politics? Well luckily, today, we have someone to help us make sense of it all.

JENA: Would it be okay if I call you Dr. Senator Frist?

FRIST: Preferably in that order, because nobody likes the politicians these days.

From the Freakonomics Radio Network, this is Freakonomics, M.D.

I’m Bapu Jena. I’m a medical doctor but I’m also an economist. Each episode, I dissect an interesting question at the sweet spot between health and economics. Usually, I take a close look at a study that answers one of these questions. But sometimes, I get the chance to talk to someone, not about a study, but about their life.

Today on the show: Dr. Bill Frist, a transplant surgeon who represented Tennessee as a U.S. Senator from 1995 until 2007. For four of those years, he was also the Senate majority leader for the Republican party. Senator Frist tells me what it was really like being a doctor among so many career politicians …

FRIST: I had my challenge just trying to explain to 60 lawyers the intricacies of embryonic stem cells.

And how his experience as a doctor influenced his political thinking.

FRIST: It was not right where President Bush was. I remember getting a call from somebody very close to him. He says, “What are you doing?!”

Before we hear former Senator Frist’s thoughts on how his background as a doctor shaped him as a politician, I wanted to know a little bit about how he got into medicine in the first place — and what made him run for office.

FRIST: I grew up in Nashville, Tennessee, the last of five children to a dad in primary care — internal medicine. Had two brothers who were doctors. One went on to found the Hospital Corporation of America; he kind of went the business route after he did all his training in surgery. So, grew up going on rounds with dad, the expectation that I’d be a doctor. Although, I got interested in policy early on, in high school, went to college and started writing for a newspaper and started getting involved in the policy world as well.

JENA: Gosh, medicine really runs the family. Now, so your dad was a primary care doctor. Was he upset that you went into surgery, or did he want you to go into primary care?

FRIST: He thought I’d lost my mind. I did have both of my brothers who were surgeons, but he said, “I just hope this last one is not crazy enough to go into surgery.” And I ended up gravitating to surgery.

JENA: So, why did you choose transplant surgery?

FRIST: It really was this idea of being able to intervene dramatically. I knew that I wanted to participate on the creative — the innovative side. The side of a frontier that could be conquered. And that’s been a constant in my life. I’m not particularly innovative. I’m not gifted there, but I’m fascinated by it. And in medicine, as you know, and in surgery, if you put in the hard work and you get in the right environment, if you focus on it, you generally can accomplish it.

JENA: So, how long did you practice then before you went into politics?

FRIST: Went to medical school for four years, then an internship, then five years of general surgery, and two years of thoracic. And then — it was really interesting — in Boston at the time at Harvard at Mass General and Brigham and Beth Israel and over at Tufts — they all got together and put a moratorium on heart transplants. And this was, like, 1981. They all got together and said heart transplants were too experimental. To me, coming out of Nashville, Tennessee, I had gone to Harvard. I’d gone to Mass General because of its innovation, its long legacy of history — killed me, killed me. So, I finished my chief residency at Mass General and went to Stanford. And that was the one place in the country that basically said, “We’re behind the innovation. We’re ready to go.” So, I left Boston and went out there, spent two years, then came East and started the program at Vanderbilt, the transplant program, which I’ll have to throw in for our listeners, that it is the largest heart transplant program in the world right now.

JENA: So, you must have been a little bit crazy, because who would leave the nice weather of Boston to go to Northern California? Why would anybody do that?

FRIST: Ah, yeah, that’s right. Well, the next job from California to Tennessee, people could ask that question in a serious way.

JENA: So, if I did my math right, you were training to be a surgeon for 85 years before you changed careers.

FRIST: You know, yeah. That’s exactly right.

JENA: Or it felt like 85 years, sorry. So, you studied public policy in college, you were involved in political thinking early on. What made you make that transition? It’s a huge transition, obviously, to go from being a transplant surgeon, to being a senator. What happened?

FRIST: Going back to my dad — I remember talking to him one night and he said, “You have lost your mind. You have the opportunity to transplant human hearts and take people who’d die within six months and give them 20, 30 years of life. And you’re going to this world of politics and rancor and partisanship.” Yeah, and we had a conversation because I’d taken that oath, as you have, to do no harm. If you’re in the business of healing, and that’s your mission in life, and you see the hope and you see the healing, the place that you can have, probably the biggest impact is public policy. Because you’re doing policies that are global, not just in the state, not just in the hospital, not just five miles away. I’ve operated on 10,000 patients. But what if you could do something that could have an impact on 20 million patients?

JENA: People enter politics from all walks of life — from teaching, from law enforcement, in your case, being a doctor. And, you know, I got to imagine that each one of those paths probably teaches them something that’s relevant to politics and policy. When I think of medicine, for example, I’m thinking about interacting with people from all walks of life, interacting with people when they’re vulnerable, making high-stakes decisions with sometimes big consequences. And — and I’m curious, you know, was there something that you learned as a doctor, in training, being a surgeon, that prepared you for political life? And — and by the way, the answer cannot be the Krebs cycle from biochemistry.

FRIST: It’s kind of hard to understand how you do take that jump from, literally, the operating room every day and taking care of lots of patients, both for acute care and chronic care — because I took care of these transplant patients afterwards — to the United States Senate, where you have a hundred people, you do have partisanship, you have this choice between Republican and Democrat. The United States Senate had not seen a physician in over 60 years. And then you’re in a room with 60 lawyers, whose mentality, whose whole culture is totally different, as, as you can imagine. And then I came in as 100th in seniority. And seniority is determined by whether or not you served in public office. Have you been a Senator? Have you been a Congressperson? Have you been in appointed office? Well, I’d been in none of those. I’d never run for office, never served in office. I just jumped.

JENA: Yeah.

FRIST: Then, over a very short period of time, I was in a leadership position of that body and there are big egos there. But that group of people elected me to leadership after six years, and then two years later to the No. 1 position — majority leader. So, am I a good politician? No. I mean, I have got to be okay, but that’s not what I was trained to do. I think what people saw in me was, No. 1, trust. When you jump from a room that’s 100 percent built around trust, a relationship that is intimate, that is personal, that is sacred in many ways. And then you’re in an arena of that Senate floor with 99 people who don’t come from that world. They have pieces of it. And lawyers do, you know, good things and bankers do good things and career politicians — I don’t know if they do good things or not, but they’re in there.

JENA: They do great things, great —

FRIST: Yeah, yeah. They do great, yeah — but to see somebody come in whose life is built 24 hours a day around trust, and then the second thing, is the ability to assimilate, based on a limited amount of information be able to, one, define the problem and that’s make a diagnosis. But that’s not enough. To engage in a treatment plan. And again, go to the world of policy. You can say there are lots of things bad, but then to come up with a solution. And you don’t know if it’s the right solution, but based on that limited information, you’ve got to make a decision. Am I going to transplant this person’s heart? Or am I not? They might live for another year or so, or two years, or three years and so, I shouldn’t transplant, but you have to make that decision. And I’m held 100 percent accountable, 100 percent for how well that person does. And I think that accountability, which is so inherent in the training of doctors, is the big distinguishing thing after trust.

JENA: You know, some people have an accountability that’s inherent to their personality. That’s the way they see the world and the way they treat others, and they hold themselves accountable. The interesting thing about medicine is that you are trained to become accountable and to understand the importance of that. So, let me just piggyback off my earlier example. Let’s say you have a politician who had a background in law enforcement. It wouldn’t be crazy to think that they would think differently about issues around criminal justice reform than someone who didn’t have that background. And a lot of politics deals with issues that are really salient in people’s health lives — involve healthcare. How did your background as a doctor prepare you for those issues or help you at least kind of shape the beliefs that you have about healthcare?

FRIST: It comes down to ethics, and by ethics, I mean issues around equity, vulnerable populations, empathy, but also objectivity. In medicine and in the transplant — in that world, when somebody comes through the door, you treat them equally. And that is something which I carried with me and I think really has a huge impact. Related to that is the focus on vulnerable populations and populations who may not have had the opportunity. It may be health insurance. It may be family issues. It may be living in rural communities. Vulnerable populations are populations in medicine that we gravitate to because of the culture of medicine. And so, to be able to see through with the objectivity and the focus on vulnerable populations and being able to take that to the United States Senate or policy issues — it’s why I gravitated to big, global, worldwide issues like HIV/AIDS. I think that all came from medicine.

Senator Frist, when he was Senate majority leader, led legislation that provided resources and prevention measures to combat AIDS in underserved communities. It’s clear that Senator Frist, a Republican who represented a red state for many years, didn’t always agree with his party’s politics. But even though he’s out of public office, I still wanted to know if this is something he’s dealing with today, during the pandemic.

FRIST: The mayors were telling me that vaccines are important, but I have a governor who’s sending a mixed message, a president who’s giving the wrong side of information.

*          *          *

Joining me today on Freakonomics, M.D. is Senator Bill Frist, a doctor who represented the state of Tennessee in the U.S. Senate for more than a decade, and who served as the Republican Majority Leader for the Senate. Before the break, he told me how his life as a doctor shaped how he approached being a politician, in general. But I was also curious to hear if there were specific examples — maybe of specific policies or laws — in which being a doctor shaped how he thought about an issue. One example he gave was the expansion of Medicare — which, in part, added prescription drugs to the federal health insurance program. Senator Frist helped lead this expansion back in 2003, and today tens of millions more people are insured because of it.

FRIST: I had some credibility because, A, I was a doctor. B, I had the advantage of being the only one there, but, C, Republicans generally did not lead on expansion of programs — they did not. I turned around and basically said, “If you want innovation and improvement in the way care is delivered to seniors, this is the vehicle to do it.” I make it sound easy, but as you can imagine, being from a red state like Tennessee, even as majority leader, it’s not that easy.

JENA: Those changes happened at a time when there was already a lot of innovation that was happening in medicine. I mean, it means something different to expand Medicare in 1965 or 1970 than in 2000, when we had new treatments for heart disease, new treatments for cancer. I mean, the importance of insurance when medical care is as innovative as it was at that time — and it’s continued to be — can’t be understated. So, I’m just going to give you a tangent thought I had. When you said that you were the only doctor in the Senate, the first question that comes to my mind is: how often were other senators asking you to prescribe them antibiotics? You don’t have to say any names. Did it ever happen?

FRIST: Yeah, no. You know, I think to be honest with you, I’m not sure about the antibiotics because you would think that they would, but — I won’t, I won’t mention them — but two of the highest-ranking Democrats, I had — this is the honest truth. I don’t know if I’ve ever said this but in the drawer of the majority leader’s desk. In that top drawer, I had the complete medical records of the two oldest people in the Senate at the time, just in case. So, a lot of medical advice along the way.

JENA: So, what you’re telling me is that you were violating HIPAA —

FRIST: Yeah. Well, you know, the other thing you said, I have to mention, I helped write HIPAA. and I was on the health and labor pensions committee at the time. So, I may have been — no, not really. They gave them to me.

JENA: So, I think you kind of alluded to this, at least talking about your constituency in Tennessee. Was there a time when you found yourself just taking a different position from your party, your colleague, your constituents, based on your medical and science background?

FRIST: Oh, yeah, a lot. And it’s played out in the pandemic as well. I put a huge emphasis on science and what the science says. And science changes as you know, and that’s intuitive to us, but it’s not to a lot of people, who think science is just there. Probably a more direct example would be embryonic stem cells. Embryonic stem cells in 1998 were really new. We’d used them in bone marrow transplant, uh, a lot. Adult stem cells have been used, but the embryonic stem cells really weren’t even talked about until 1998. And I was of a standpoint that in an ethically sensitive way, we should continue to do research on embryonic stem cells, and I think I’ve been proven to be generally correct. But at the time, most Republicans were opposed to using all embryonic stem cells and felt we should stop all research. My experience with the transplant world — I knew of the huge potential power of embryonic stem cells. So, I and President Bush took sort of a mid-position, but his center of gravity was much more to the pure, pro-lives, “Let’s not use many cells.”

But I basically wrote and was very clear on the Senate floor, that we — in an ethically, really sensitive, strong way with all sorts of constructs — we should do more research. And so, people knew I was for embryonic stem cells, ethical use of them. But it was very much against my party, and it was not right where President Bush was.  I remember getting a call from somebody very close to him and says, “What are you doing?!” That’s one of many examples.

JENA: So, your statement reminds me of the study I did a few years ago. You know, I’m kind of broadly interested in how physicians think and there’s a lot of interest in how payment incentives and physician training and experience influence the way they practice. But one thing that’s sort of been interesting to me is how their political beliefs or thinking about the world influenced the way they practice. And so, we did this study where the main question I tried to answer was whether or not there’s any difference between Republican doctors and Democratic doctors and how aggressive they were at the end of life — sort of your points, sanctity of life and I didn’t find any difference between Republican doctors and Democratic doctors in that way. And that was sort of reassuring to me in the sense that, you know, we know politics imbues medicine and healthcare, but here is one area — at least end-of-life care — where it seemed not to affect the decisions that doctors were making. And I’m just curious, any thoughts on that particular finding as it relates to your views on end-of-life care, or just more generally, how does your politics shape the way that you practice care when you are treating patients?

FRIST: First of all, I think the study is a great study, because it does give the construct, the discipline, and the evidence for what I agree with totally. I approach it by the fact that in medicine you do take an oath and people say, “Well, people break oaths all the time,” but I think part of our training and our culture — and a very good part of — is the definition of what a profession is. And a profession has two criteria. One is a specialized body of knowledge, which is obvious. We spent years and years getting it. But the second is a central course of ethics. And the ethics we say do no harm, but the do no harm is much more than the do no harm. It is everything is centered on your patient and not you. And I think that becomes the single dominating ruling, a sort of ethical premise and core that ultimately dictates what is done. I’ve been involved in the business world a lot in the last 16 years. I started what became the largest, non-hospice based palliative healthcare company in the country.

It’s called Aspire Health, went to 35 states. I don’t run it now, but we’d ran it for about six years. Started it and ran it. And it’s community-based. And there is no question in my mind that the politics of doctors would not enter there. It could be — not the politics, but the value systems — it could be different if you looked at the early stages of life, reproductive rights for women and the like. And as a doctor, I got in the middle, you know, it’s something you have to deal with if you’re going to represent America, you have to jump in. As an individual, it’s pretty easy. You know what your value system is, but as you represent people broadly, and like embryonic stem cells, you have to go beyond that and listen to other people’s values as well.

I want to pause for a moment and reflect a little bit about what Senator Frist just said, about the tension between his own value system and those of others that he may represent. You may recall that in the last episode of this two-part series on politics and medicine, I mentioned the case of Terri Schiavo. She was a Florida woman who had severe, persistent brain damage after suffering a cardiac arrest. Her husband wanted her feeding tube removed, but other family members didn’t want that. Terri’s case exploded in the media, creating national controversy between Democratic and Republican legislators, including then-Senator Frist and Florida Governor Jeb Bush, both of whom supported legislation to prolong Terri’s life. In his autobiography, Senator Frist described how, politically, he knew it was probably best to steer clear of the Schiavo case, to not address it. But morally, he felt like he had to weigh in. And he was criticized for his involvement. But, as he wrote, and I quote: “The Shiavo case was a lot more complicated and nuanced than most people realize. Still, I can’t bring myself to believe that, knowing what we knew at the time, the actions we took in the case were inappropriate. To this day, morally, I believe it was the right thing to do.”

I obviously wasn’t there, but this is a complicated issue. You see, almost all doctors, at some point, have taken care of patients at the end of life. They see first-hand how medical miracles can happen, but also how, for most patients at the end of life, miracles aren’t the norm. The process of dying is painful for everyone, and seeing that, a lot of doctors are hesitant to recommend things that prolong life without a clear path to recovery. And I get that. But one thing we may not be good at is putting ourselves in the shoes of others. It’s hard to let someone go. It turns out that, as doctors, what we think others should do might not be the same as what we would do. Some research actually suggests that’s true. A study published in JAMA by Dr. Joel Weissman and others found that doctors, who would presumably be most familiar with what end-of-life care looks like, were only slightly less aggressive when it came to their own end-of-life care compared to the general population. Another study by Dr. Hanna Wunsch and others also found that the care doctors receive at the end of their lives is actually not that different from the care that non-doctors receive. In their study, doctors were, again, only a little bit less likely to spend their last days of life in the hospital. To me, what these studies tell us is that when it comes to end-of-life care, things may not be as black and white as they seem. Our experiences as doctors can certainly help inform patients and families about what to expect at the end of life, but for all of us, our beliefs and values as people have to carry us the rest of the way. A recent episode of Freakonomics Radio called “Does Death Have to Be a Death Sentence?” explores the very nature of our approach to end-of-life care, and it’s worth a listen.

But anyway, back to the interview, where I had a related question about a different tension — the tension over vaccines.

JENA: You mentioned this earlier. One of the issues that has been politically polarized in the pandemic relates to vaccines and what people sometimes call vaccine hesitancy. And Tennessee has had an issue with this in terms of vaccination rates. How do you square that issue, which is politically polarized, in your mind as a doctor? Are you doing things to try to increase uptake? What is your general view on how we’ve handled the pandemic? What are the political responses, and so forth?

FRIST: You know, we’ve learned so much from the pandemic and we’ll continue to talk about it. We just released in Nashville a really superb roadmap for the future for re-emerging viruses based on the early experiences. And I encourage other cities to do that now. Everybody listening to us right now needs to up and pay attention to health literacy. Being the only physician in the United States Senate, I had my challenge just trying to explain to 60 lawyers, you know, the intricacies of embryonic stem cell. If you’re in rural Tennessee now, and you have a governor who implies — and it may be the media, and it may be whatever — that masks are not important or that vaccines are not important, that your individual freedoms trump everything, and you have a president at the time, which is all over the place and proposing things that haven’t been proven scientifically — the mayors, as I travel around the state, were telling me that, “I agree with you, Dr. Frist, Senator Frist, that vaccines are important, but at the same time, I have a governor who was sending a mixed message, a president who’s giving the wrong side of information.” And all of that comes back to this lack of preparation.

In 2005 and 2006, when I knew I was leaving the Senate, I wrote a lot about communication in times of pandemics — pandemics that inevitably are going to occur and they’re going to occur again. And I began every one of those speeches with the importance of communication. And so, our country failed in terms of communication — not just Washington. It’s too easy to blame Washington. But I would say across the board. And doctors did not really get involved and they didn’t really help as much as they might early on. A few did. And a few didn’t. And I think that the health-literacy end of things — we’ve just got to do a better job. Lastly, we did not do well early on testing. I’d give the country a D in terms of how we handled the testing. But the speed that we got the vaccine to people — the scientists coming together, the partnerships between our federal government funding the greatest scientists in the world, the scientists and all their dynamism and innovation that we talked about coming together to deliver a vaccine. I’d give that an A plus.

JENA: The first episode of this podcast I described a study that we did, it’s kind of a funny study, but it’s based on our daughter. She had a birthday a couple of Decembers ago. And we decided to host a Zoom party and not do it in person. We were worried about Covid. And it made me think, you know, I wonder if you look at people who have birthdays versus don’t have birthdays in any given week, and you look a couple of weeks out, do the kids who have birthdays, are they more likely to have Covid diagnosis? And we found that in the two weeks following when a household had a single member with a birthday, the rates of Covid-19 infection in that household went up about 30 percent, which told us something about how even though you know and trust the people around you, if you do things like have birthday parties in the middle of a pandemic, you run a risk. But one finding that came out of that study that really intrigued me was that Covid-19 birthday effect was the exact same in highly red areas and highly blue areas.

And that meant something to me because, you know, I feel like during the pandemic we have focused a lot on our political differences. You know, vaccines, masks, stay-at-home-orders, whatever it is, you know. We focused on those differences, but we haven’t thought about the fact that everybody’s paid a price. There’s nobody in the pandemic who’s gone through it without paying some sort of price. And it kind of leaves me with the sense that there’s this shared experience about the pandemic that has really been lost in comparison to the magnification of the ways that we’re all different. Do you have thoughts on that?

FRIST: Oh gosh, yes. I think it’s really important because it’s so easy to fall in these polarizing views of the world because of what you see in Washington, D.C. You see this 50-50 Senate that are literally in two different worlds. And what that leaves out is the middle of where most reasonable people are. You know, most of these things you read in these medical journals are pretty good, but they’re so tiny and finite, you can’t apply it to anything. But yours, looking at those small gatherings — which we all have — your findings are applicable to, you know, most things that we do in life. So, I love the paper. And I love that kind of science. But just another example of bringing people together. Since I’ve left the Senate, I’ve gotten very involved in environmental movements and I’m vice-chair of a group called The Nature Conservancy. And we look at clean air, clean water — all the health implications.

But the other thing we look at is climate change, which is arguably the largest existential issue that’s out there today. And if you say climate change in Tennessee, again, a big red state, people immediately go to either the left, the blue and the extreme. Or the right, the far right, which basically says, “I don’t believe it.” But neither side’s doing much on the solutions coming together. And so, what Covid has done is driven people to nature, all of which is affected by or tied in with climate change to bring issues, which are highly polarizing today, and we’re creating a movement here in Tennessee for people — young people who, hopefully, as they mature and get older, and become leaders in their communities, they won’t fall into these polarizing camps, which we have today.

JENA: We’re running up on time. I have one last question. This is, maybe, more of a reflection on myself. I spend, now, most of my time doing research, I’m obviously doing this podcast. I still see patients at Mass General, but a lot less than I obviously did when I was training. And, you know, I do worry about spending a little — too little time taking care of patients and what that means for me as being a doctor, though, it means a lot to me, so I got to ask you if someone dropped you in the middle of an operating room today, what do you think? You still have it, or no?

FRIST: Do I have it? I know I can do the operation and now because I have a little bit of an advantage in that I left doing my last heart transplant in the mid-1990s. But since that time, I’ve done over 20 medical mission trips around the world, doing surgery in about 13 different countries. So, I have a little bit of an advantage in that I never went cold turkey. I will have to say the last five years, I have not been doing active surgery. But up until then, I was doing a surgery every year.

JENA: So, okay, another way to put it is if you’re on a plane flying from, let’s say Nashville to Boston, and a flight attendant calls for an emergency, you’re not going to pretend like you’re asleep?

FRIST: No, no, no, no, no.

JENA: Well, look, I appreciate you taking the time. Hope we can keep in touch.

FRIST: Yeah, let’s do it again. Really appreciate the chance to be with you.

That’s it for today’s episode of Freakonomics, M.D. A big thank you to Doctor-Senator Frist for taking the time to talk to me. He has a podcast of his own; it’s called A Second Opinion. If you’d like, please send me your thoughts about this or any episode. I’m at bapu@freakonomics.com. And, if you’d be so kind, leave us a review wherever you listen to this show. It really helps out. By the way, we updated this episode since it first aired, because we described the nature of Terri Shiavo’s condition incorrectly. Thanks to the listener who flagged that for us.If you’re interested in learning more about the show, or if you want to check out the transcript for this episode, that’s all at freakonomics.com. Thanks for listening.

Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. Original music composed by Luis Guerra. This episode was produced by Mary Diduch and mixed by Eleanor Osborne. The supervising producer was Tracey Samuelson. Our staff also includes Alison Craiglow, Greg Rippin, Rebecca Lee Douglas, Morgan Levey, Zack Lapinski, Ryan Kelley, Jasmin Klinger, Emma Tyrrell, Lyric Bowditch, Jacob Clemente, and Stephen Dubner. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.

FRIST: Have we — have we met before?

JENA: I — I think we’ve met. I have some recollection of some sort of Harvard Medical School board meeting, maybe I gave a talk — but it was a while ago. This was before I had kids. So, everything after — after I had kids, you know, I’d forgotten about.

FRIST: Isn’t that true? Isn’t that true?