BRIAN LAMB: Dr. John Garrett, Chairman of the Board of Directors at the Virginia Hospital Center, can you remember the first moment you thought you might want to be a doctor?

DR. JOHN GARRETT, CHIEF OF CARDIAC SURGERY & CHAIRMAN OF THE BOARD OF DIRECTORS, VIRGINIA HOSPITAL CENTER: I think so. My stepfather was a surgeon, and for lots of reasons, wanted to be like my stepfather.

So from the – from about age seven when he came into my life, I kind of wanted to copy him. I think it got a little more serious that when I was in high school. I injured my hip. I dislocated my hip in a skiing accident, and you had to be in the hospital in those days for about seven weeks with a pin in my knee and traction and had a lot of time just to lay out and observe people working in the hospital, and I think in my mind, I really decided then that I was going to do it.

LAMB: Where'd you grow up?

GARRETT: I grew up in Montgomery, Alabama.

LAMB: Where did you go to college?

GARRETT: I went to Emory University in Atlanta for undergraduate, and then I went to medical school at the University of Alabama in Birmingham.

LAMB: When did the heart part of all this get into your life?

GARRETT: Yes. The medical school at Alabama had a very, very strong cardiac surgery program led by a man named John Kirkland, who was one of the world's greatest cardiac surgeons.

And so cardiac surgery was highly visible even to medical students, and that's sort of where I got to see heart surgery for the first time, and then when I began my surgery training and I did an internship, and one of the things I rotated through was cardiac surgery, and Dr. Kirkland was my mentor, and it was a very brutal six weeks of very little sleep and hard work, and but when you finished it, you sort of felt like you'd been through Marine boot camp. You were proud of what you did, and I remember when I finished that, Dr. Kirkland put his arm around my shoulder and in a very uncharacteristic way said, You ought to consider doing this.

And from that moment on, even though my stepfather was a general surgeon and we had always talked about me doing that, after that I was cardiac all the way.

LAMB: When was the first time you did an actual heart operation where you opened the chest and what was it and where was it?

GARRETT: Yes.

LAMB: You're on your own and you're the boss.

GARRETT: Well, you know it takes a long time to be a surgeon, and it takes even longer to be a heart surgeon. And so it's not like you wake up one day and you just do a heart operation.

You do parts of it with a mentor or someone who's training you. So, from the time that I was at Alabama as an intern, I actually did parts of heart operations.

You know there's thousands of different steps in any operation, and in cardiac surgery, you would do one part. And then over time, you would have done a whole operation, but never the whole operation yourself.

And so it was only when I went to Houston, Texas to train in cardiac surgery with another very notable famous man named Denton Cooley, it was there after about, I’d say, a half of a year that I was left alone to do a cardiac operation.

And I remember it, but by that time I was an experienced surgeon. I knew how to operate, but it was still an unforgettable thrill to be in charge of that patient.

LAMB: Have you ever done a heart transplant?

GARRETT: Yes.

LAMB: What's that like?

GARRETT: It's – I think it's – most people think it's more glamorous than it really is. For me, the beauty of a heart transplant is seeing a desperately ill patient who looks sick, who looks like he's dying, and you put the heart in him and the actual technical part of a transplant is not very difficult. There are big stitches that you put, big suture lines, but literally instantly by the next morning the patient has a different look. And that's the most thrilling thing about that is it just takes no time at all for the patient to look just magnitudes better.

LAMB: Are you ever frightened in the middle of an operation?

GARRETT: No. I don't think frightened – I don't think frightening is the right term. I sometimes after an operation I’ll think what could have happened or why didn’t something happen, and that's sort of after the fact. You might get scared of what the consequences could have been.

Sometimes during really desperate sorts of operations where it really is life or death, I mean, you're just so focused in what you're doing, and you don't really – don't think about the consequences.

LAMB: What's the longest you've ever been on your feet in the operating room?

GARRETT: Probably a little over 24 hours.

LAMB: Doing what?

GARRETT: We were doing a patient who had torn an aorta, the big artery that comes out of the heart, and I was working with one of my partners, and it took – the patient bled and we couldn’t stop the bleeding, and I think if there'd been one of us there, not together, you know we might have stopped, but we were there together, and it was in our program here and our – the nurses still talk about it because the shifts changed but we didn't.

But they talk about us both sitting on little stools right by the operating table, dozing off you know waiting for this patient to – well, he wouldn't give up, and the patient eventually stopped bleeding and walked out of the hospital, and was well.

LAMB: I know you won't name the person, but – or – well, I'll just ask the question. The most difficult patient situation you ever had that you can think of.

GARRETT: OK. I have it.

LAMB: Go.

GARRETT: This is a great story. It's been years ago, but I was operating on a priest, and I had just begun taking the vein out of the priest’s leg in the operating room. I was by myself, and one of the general surgeons came in the room and said, I really need your help. We've got a young lady that has had an appendectomy, an appendics removed, but she has had a cardiac arrest. She stopped – her heart stopped and we're not sure what's wrong with her. She was about 28 years old.

So I broke scrub and went over and looked, and I thought that patient – it was a young girl. I thought that she had a big blood clot to her lung, and so I quickly ran through all of the different possibilities of what I could do, and because of – a little bit because of who the patient was, I made the decision to move the patient out of the operating room, which is really not a standard thing to do, and move her into the operating room, and I opened her chest emergently, opened the artery where I thought the blood clot was to save her life, and the blood clot wasn’t there. It wasn't – there was no blood clot.

So there I was with a patient I'd moved out, I had this patient who I've made the wrong call on, and so then I started feeling around her heart, and she had some blockages. I could see a – in her coronaries, and so blindly, which is again very substandard, I did three bypasses into these blocked arteries, and she came off the heart lung machine with a little difficulty, but the next day or later that day I woke the priest up and said you know, We got some good news and bad news for you, but the you know the good news is you saved another lady's life tonight, and the bad news is that we didn’t do your operation today.

The end of that story is that girl lived, and she's a beautiful girl, and it was a great story. She became friends with the priest, and he felt very much involved with her situation. We ended up cathing her you know later. You usually cath patients before you do bypass surgery on them.

LAMB: What's that mean?

GARRETT: Cathing is when you stick a catheter into the heart arteries and squirt dye, and you see what blockages they have in their arteries.

But we did that after I had bypassed her because when I bypassed her I really didn't know what was wrong. I mean, you just feel some hardened areas on her heart indicating blockages.

And as it turned out, those – the grafts that I did were just the ones that she needed. And so you know I think that she got sort of just what she needed, but it was not the standard way that you get that.

LAMB: When patients come to you, what can you almost always predict they'ree going to do when you start to talk about their condition?

GARRETT: You know more than you think, at least in cardiac surgery, patients – they really have a high degree of trust for you, and a lot of patients don't want to know a lot of detail. I think it's pretty different in cardiac surgery and other specialties. Although more and more patients will have been on the Internet, reading and learning things.

But so many patients just want you to do what you do, they're grateful for it, they don't need to know a lot of details, they're interested in when they can go back to work, they're interested in the likelihood of them dying.

But a lot of the other details I think they're not too interested in, and so it really puts the burden on us to, I mean, we – there's certain things you need to know, and we try to tell patients those things even if they're not too interested.

LAMB: So, you're in the operating room. Let's say you're doing a bypass surgery. How many people are in there with you and what do they all do?

GARRETT: Well, before I answer that, the team in heart surgery is critical. I've been blessed with a team that we've been together for 20 years and there's been very little turnover, and we really learned each other. It's like family.

There's an anesthesiologist, who's a doctor that puts the patient to sleep and manages the drugs and all during the case. He has a helper.

And then at the operating table, I have an assistant, and I operate with a nurse, an RN first assistant, and I have three of these people, and I'm more comfortable doing a case with one of my RN first assistants than I would be with one of our partners because I have their total attention, and they know exactly what my routines are. They're nurses. They're nurses, and they're extremely skilled nurses.

Next to me, the person who passes my instruments is called the scrub, and then in cardiac surgery we usually have one other person at the table called the second assistant who is there to hold the heart back, to retract the heart so that I can see where I need to operate.

And then in the room itself is a person called a circulator, and the circulator is another nurse who is the person who gets you the things that you need. If you need another stitch or another instrument that's not there, that person gets that.

So that's pretty much a standard open heart team, just bigger than a typical team in a typical operating room.

LAMB: You said you'd done this here for 20 years at the Virginia Hospital Center …

GARRETT: Yes.

LAMB: … did you come here in 1989?

GARRETT: I did.

LAMB: From where?

GARRETT: I was in – I finished my cardiac training in Houston in 2006, and …

LAMB: Two thousand and six or …

GARRETT: Excuse me. Nineteen eighty-six.

LAMB: (INAUDIBLE).

GARRETT: Yes. And you know heart surgery you can’t just go somewhere and start doing heart operations. It takes a hospital that will give you the equipment and the team that you need. It takes a lot of resources.

So, one of my friends, dear friends and I started a program in Auburn, Alabama, at East Alabama Medical Center, and we were there for about two years, and we brought nurses from Birmingham and I brought a staff from Houston, and we started this program there, and during that time there, the hospital here began plans to have open heart surgery here, and they went on a national effort to recruit surgeons, and we were included in that, and we came up and looked at the facility and the city. You know I had always wanted to live in Washington, but in 86 there was no opportunity for me to come here, and this gave us an opportunity, and we left on good terms in Alabama and moved up here in 89, and started the program.

LAMB: Why did you want to live here?

GARRETT: Well, it was Washington. There's a lot going on here. I';m all into food and not so much into the culture, but my wife's into culture, and we liked living – we wanted to – we weren't too happy in Alabama. We wanted to raise our family in this area.

LAMB: Where did you meet your wife?

GARRETT: My wife was – I was a Chief Resident in surgery, and one of the medical students was on my service, and her best friend was my wife, Mary, and Mary was – we had a blind date, and in those days I drove a little beat up car, a little Volkswagen. It had holes in the floor, and all the girls I'd go out with were just in about the first 15 minutes complaining about the car and Mary got in the car and never even noticed that there were holes in the floor, and that's kind of the first thing I liked about her.

LAMB: Mary does what today?

GARRETT: She's a pediatrician. So she's in the office next door, in with a group of pediatricians here on campus.

LAMB: So, you all work together, then, in effect, in the same building?

GARRETT: We do, yes. We do.

LAMB: Now, there's a big difference between being a pediatrician and being a heart surgeon.

GARRETT: There is a big difference, yes.

LAMB: First I would suggest is the difference in what you make.

GARRETT: Yes. Yes, pediatricians, I think they're the – I think that they're not really well paid. It would astound you, I think, to know what a pediatrician makes.

You know if you consider the amount of training that they have to go through and expense that they incur to get to where they go.

LAMB: For the last 11 years you've been Chairman of the Board of Trustees or Chairman, I don’t know what – do you call them trustees or board members or?

GARRETT: Yes.

LAMB: At this hospital. This is a community hospital. Is it nonprofit, and if so, why?

GARRETT: Yes. We are a not for profit hospital, and if I could, let me just take a minute and describe what that means.

Not for profit hospital doesn't mean we don't make money. We have to make money. But it means that we don't have shareholders, that we're not responsible to anybody but our community.

We are a 501(c)(3) organization …

LAMB: Tax exempt.

GARRETT: Tax exempt, and basically what we do here is we try to either break even or have a small margin of profit. Last year we had a 1.6 percent margin, all right? So what we do with that profit is we invest it back into equipment. You know we try to have the latest and greatest that medical science has to offer.

Two years ago we purchased a $7 million dollar cyber knife. That's a very specialized piece of radiation equipment. But that's what we do with our money. We don't give it out to shareholders. But it's not to say that we don't need to make income. We have – we employ a lot of people, and you know this is not charity.

LAMB: Gross revenues for a year here?

GARRETT: About 288 million.

LAMB: How many people work here?

GARRETT: A couple of thousand.

LAMB: How many of those are doctors?

GARRETT: We've got about 300 on our active medical staff. Right now only a handful of those doctors are employed by the hospital, so most of the medical staff here is an independent medical staff.

LAMB: There's noise in the background right now. Do you have – do you know what that is?

GARRETT: It's some sort of alarm, and I don't know what it is because I don't work down here.

LAMB: This is where in the hospital?

GARRETT: This is in the emergency room, and this is what's called a fast track part of the ER, and so if you come in, you know you hear these disaster stories about coming and waiting three hours before you get seen in the ER. This is a part of our ER where we try to avoid that. It's called the fast track. We get you in here and get you out without having to wait so long.

But I don't know what that alarm is.

LAMB: I tell you what we'll do, we're going to – we'll just stop. We don't normally do this because it's not annoying to us, it's annoying to the audience as they listen to it.

No, there it is. It stopped. We can keep going.

Why did you take on the job of Chairman of the Board? And how much time in your day do you spend doing that job?

GARRETT: Yes. Well, I took it on because it was something else that I could do. You know I sort of worked my way up to leadership you know here in the hospital, and then I got on the hospital board, and then I felt like I was a you know I made some reasonable contributions, but I didn't feel any – that I had any sort of special ability.

The previous Chairman, a man by the name of Pat Healy, you know when he was going off, he encouraged me to run for the chairmanship, and I really didn't think that I had much to offer. But you know I did, and I was elected, and you know I've grown into the job over the years.

I work here. My office is here. I'm here a lot, and so I do spend time every day with chairman sorts of things, but I think probably the one thing I have done is to provide vision for excellence in clinical care, in the programs that we've developed here. An example would be the, for instance, the neurosurgery program, my cardiac surgery program, the accredited – nationally accredited Center for Breast Health.

These are programs that we have really had the vision to bring forward. In the hospital that we’ve built, you know we have – we offer all private rooms to patients, regardless of their need to or ability to pay.

LAMB: Why?

GARRETT: Because we could. It's the best thing for the patient. You know years ago, you could stay in a hospital for five days with pneumonia and it wasn't so bad sharing a room with someone.

Nowadays if you're in the hospital, you're sick, otherwise you're out. You're discharged. And so it's really – I think it's unacceptable to share a room in this age with another sick person. It's better for the patient to have a private room. That's the main reason we did it. And that's sort of the main thing that we've pushed is to try to do what's best for the patient.

LAMB: You have 320 rooms?

GARRETT: I think we have more like a 350 something.

LAMB: I was just reading the literature…

GARRETT: Got it.

LAMB: We came here and asked you to do this because a lot of us use this hospital. We live in this area. A lot of our employees go here, a lot of government workers come here, a lot of members of Congress and all that.

As you sit and listen to the debate over healthcare, what is the first thing you'd like to tell somebody that's – that they don't really know what they're talking about?

GARRETT: Well, I guess everybody knows it's complicated. OK. For starters, you have a hospital, about half of what we do here is Medicare and Medicaid, so about half of our admissions in this hospital, Medicare and Medicaid, we lose money on all Medicare and Medicaid patients. Medicare and Medicaid covers at best about 80 percent of the cost, not the charges, but the cost, all right?

And so the thing that I guess I want to tell people is that so far what we've seen is the government's – the regular government controls cost, they just pay you less, and we take that, we accept that, but we would have to change what we do if not for the private insurance carriers whom we aggressively negotiate with to get rates that are 140 percent of Medicare.

Because we're able to do that, we're able to make our 1-1/2 percent margin so that we can buy a cyber knife for $7 million dollars.

LAMB: Let me stop and ask you, our company has full insurance. So what you’re saying is that we're really paying to make up the difference between Medicare and what it costs?

GARRETT: Yes, you do. You're …

LAMB: Through our insurance.

GARRETT: Your insurance does, right. If we didn't get that extra money from your company, if all we got was what Medicare paid, then do the math. We lose 20 percent.

Well, we're a business. We can't lose money. So we either go out of business or we offer less so that we can break even.

Well, offering less in healthcare means that we don't give you the latest and greatest, which you know is not as good.

LAMB: Who sets, though, the costs? In other words, you say that this – I mean, let me ask you this. If you do a heart bypass …

GARRETT: Yes.

LAMB: … what's that cost?

GARRETT: Well, there are two different – they're – let me tell you how it works. Doctors charge separately in the hospital. So, if I do a Medicare operation, a Medicare coronary bypass surgery, I accept what Medicare pays me.

LAMB: What's that?

GARRETT: It's about $2,000, OK?

LAMB: And what do you do for $2,000? What's the total amount of your time spent doing?

GARRETT: Well, surgeons are paid globally, so you know if I operate on you, I get one payment and you and I are married, OK? So, for that month or until I get you well, that's what I get paid. So, I can see you 10 times a day, I can you know if you have complications, come in in the middle of the night, do whatever it is, I get that one payment, OK?

And for the hospital it's similar. They get what's called a DRG payment, and it's based on the diagnosis. So, for bypass surgery, I think it's about $18,000 that the hospital would get from Medicare to pay for whatever happens to that patient.

LAMB: And that's a total cost of $20,000 for a bypass?

GARRETT: Yes.

LAMB: That Medicare will pay?

GARRETT: Yes.

LAMB: What's it really cost?

GARRETT: Well, it costs more than that. I'm not sure exactly how much more than that. I mean, my – we're way beyond what we charge, OK? What we charge and what we collect is totally different.

LAMB: But at that point, if Medicare's going to pay 20,000, who determines what the insurance company will pay?

GARRETT: Well, we negotiate with the insurance company.

LAMB: Do they negotiate off the Medicare price?

GARRETT: Absolutely. And that's part of the rub is that we feel like that's a little bit of an unfair floor. Medicare sets the rate, and everybody wants to go there.

But we lose money with the floor rate that Medicare sets.

LAMB: How does Medicare set the rate?

GARRETT: I don't know.

LAMB: You have no idea?

GARRETT: No, I don't.

LAMB: Is that frustrating for you?

GARRETT: Well, I'm sort of past being frustrated with it. It's you know it's the law, and but it's really different now than it used to be.

LAMB: What did it used to be?

GARRETT: There used to be just more money….

UNIDENTIFIED PARTICIPANT: Anesthesia and respiratory therapy stat to room 738.

LAMB: We are in a hospital.

GARRETT: Right. Right.

UNIDENTIFIED PARTICIPANT: Anesthesia and respiratory therapy stat to room 738.

GARRETT: And even if you were deaf, you could hear that.

LAMB: Right. Go ahead. You were …

GARRETT: There used to be more money in the system.

LAMB: Why?

GARRETT: I think that it was – I mean, look, medical care gets better and better every year, OK? New technology, it's expensive, but it’s better and better. Things used to be cheaper, but you know we're of the mind that there's nothing that's too expensive. We want the latest and the greatest. We're willing to pay for it, and we have.

But that occurs at the same time in parallel that we're getting paid less, the hospital's getting paid less.

LAMB: Every year?

GARRETT: Absolutely. Physicians get paid, well, that's part of what Medicare has an ability to do is to lower what they pay you, and we have nothing to say about that. You know physician fees you know every year they threaten a 10 percent decrease in our reimbursement, and then for the past several years they've right at the very end they don't do it, and we have a sigh of relief.

LAMB: But if I'm in your position and I'm – and first of all, how much are you motivated – I know this is a hard question to answer, how much are you motivated by money?

GARRETT: I'm not.

UNIDENTIFIED PARTICIPANT: Code blue 7B room 738. Code blue 7B room 738. Code blue 7B room 738.

LAMB: Now, that's a little more startling than the last announcement we had.

GARRETT: Yes.

You know I – most doctors truly did not go into medicine to make a big income. I think at least the physicians in my generation were attracted to medicine by you know what you can do for people, and the idea that you could be independent, work for yourself, sort of be your own person.

UNIDENTIFIED PARTICIPANT: Blue 7B room 738. Code blue 7B room 738. Code blue 7B room 738.

LAMB: Dr. Garrett, we were interrupted for the code blue. By the way, what's that mean?

GARRETT: Code blue is when someone has a cardiac arrest and a team within the hospital descends upon that patient to resuscitate them.

LAMB: Would you normally do that if you were …

GARRETT: No. No. Anesthesia is sort of the key person. Then we have medical staff residents here, OK? From the universities, and they sort of lead the team. This is a daily occurrence in a hospital, and you know it brings up a point of this is what we do in a hospital is our default is to help, is to save people, and in doing that we don't think about the money. We don't. It's the last thing on a physician’s mind is what money we're spending to bring someone back.

And I think that illustrates a very important point. It's not part of what a doctor does.

LAMB: But we've been hearing, and I think in another conversation I had, we talked about this where some of the younger people coming into the business have a different attitude about money and their time than, say, people your age.

GARRETT: Yes. It's clearly different, and I think the reasons are justified, but I think that young physicians see a different horizon than guys and girls in my era, and …

LAMB: What is their horizon?

GARRETT: I think they're much more protective of their private time. I think that they're much more eager to be employed, to not have the responsibility to run their practice. I think part of that's because there's very – it's hard, the opportunity to hang out your own shingle now is very difficult. It's too expensive. You can't afford it.

And so you know young people don't want to take that risk, and there's more of a shift mentality you know. In my group, we sort of never get away from it, even on our nights off, you're still a little bit on edge. It's what you do. It's part of your life, and I think that the newer generation of physicians, there's more of a you know you work your shift, they're long hours, but at the end of things you really are off and you have your life. That is what it is.

LAMB: Back to my original question to you was what do you want to say in this debate that you think is not being heard? What else?

GARRETT: Well, let me just make a little point about tort reform.

LAMB: Explain what that is.

GARRETT: Well, you know in everything that we do as physicians and as a hospital, we have a possibility of being sued by patients or family or whatever, and it's not something that's like in the front of your mind, but it's almost ingrained in you.

And it has unintended consequences. I'll give you a really pertinent example that honestly just happened this week. I had an 86-year-old chronically ill man, it's my patient. He came into the emergency room and he had a ruptured aneurysm, so a big artery in his abdomen had popped. He was still alive. He had had recent abdominal surgery, so he had an abdomen that had been opened before, and his pressure was about 60. He was dying.

And I had absolutely no problem saying this patient is too sick to have emergency surgery. He’s not going to survive, all right?

We have new technology, new expensive technology, called a stent graphs. These are graphs that are placed inside of arteries from the groin, placed up in the aneurysm, avoids a big operation, but we have that capability.

So, because we have that capability, I sent this patient, who normally I would have just said let’s stop, down to radiology. They quickly shoot some studies. They called me and they say, We can do this. We can save him, but if we save him he will lose his kidneys. We are sure of that. OK?

Now, if I did not have the family that I could talk to at that point, I would have said go ahead. That would have committed that 86-year-old man to dialysis, and he probably would have died within a month, all right?

But I would have been afraid to not proceed on the fear of what if the family really wanted to go ahead and said you could have saved him, which we could have, and we didn’t. Fortunately I had a family who understood everything and elected to stop.

But my point is, if the family had not been available, we would have done what we do, which is to take the next step, which a lot of times is easier than saying let's stop, and that drives up the cost of healthcare.

LAMB: I understand that we're right in the middle of fast tech room for emergency room that it's in this type of place where you have a lot of defensive medicine based on the tort reform you're talking about and based on wanting to cover yourself on this.

Can you explain that?

GARRETT: Well, a lot of people that come into emergency rooms don’t want to be there, OK? They didn't plan to be there. It's not like you have a relationship with me, you picked me as your doctor, I operate on you and something doesn't work out right, that's different. Emergency room, you come in, you don't want to be there, you don't know anybody, nobody knows you. If it's really a bad situation, there's lots of things going on, things can drop through the cracks without tight protocols, and so sometimes more things are done, it's kind of like we call a shotgun approach. It's easier just to do everything than – so you don't leave anything out than to pick and choose.

And that drives up cost.

LAMB: Back to your mention of something called a cyber knife.

GARRETT: Yes.

LAMB: Seven million dollar machine. I think the first one in this area to have one was Georgetown Hospital. Is this the first one in northern Virginia?

GARRETT: It is, yes.

LAMB: How do you pay for that, and how much of that is controlling the costs? For instance, you have a $7 million dollar machine, you’ve got to put patients in front of it or you’ll never get your money back.

GARRETT: Right.

LAMB: What's it do first?

GARRETT: Well, it delivers a focused beam of radiation to a target regardless of motion and all that's going around with lungs going up and down, any kind of body movements. It's a very, very precise way to deliver radiation.

And yes, we do – we don't utilize the machine to pay for the machine, but we do pay for the machine by utilizing it. If you – if that makes sense. I mean …

LAMB: Did you have to buy this machine on time, or did you pay cash for it?

GARRETT: Well, I – we usually pay cash.

LAMB: Is that where your profit comes into the picture? Do you put that into …

GARRETT: Exactly.

LAMB: … reserve.

GARRETT: Exactly. Exactly.

LAMB: And what we've gone through your – the whole board's decision on something like this to bring it in here, what would have been the reason?

GARRETT: Well, we do a needs assessment. We looked at the technology. We compared it to other technology, and we at the time when we were recruiting a couple of world class radiation oncologists that are here, and they believed in the technology.

We really thought as a board that this would put us in the forefront of patient care in that area of radiation oncology, so that was the prime reason that we decided to do it.

We did have a business plan that predicted you know I can't remember the details, but how many years it would take to pay for itself. I mean, we don't – we try not to do things that are going to you know lose money over the time. We lose enough money just doing our routine taking care of patients.

LAMB: How much of the money that you take in every year comes from patients and how much of it comes from donations through a community hospital?

GARRETT: Yes. We don't get a lot of – we have a foundation board that's pretty new. We were out of the fundraising business for about a decade. We're back in it now.

So last year we raised about a million and a half dollars, so not a whole lot. We’re hopeful that you know that’s going to grow, but in these economic times, we’ve seen a real downturn in you know what people are able to do to support the hospital.

LAMB: How often is your hospital full?

GARRETT: It's full a lot, OK? So I don’t know the exact percentage. We try not to ever go on what's called reroute, but we have to do that several times a year. Reroute is when the hospital is full at the seams and we can't get a patient in so they have to go to another hospital.

LAMB: From your experience, what motivates someone to have a not for profit hospital versus, say, a Hospital Corporation of America, which is all profit, and which is better for the patient, better for the country?

GARRETT: Well, I think – I mean, what motivates someone to have a for-profit is to profit you know but I think not- for-profit is the best for the country because I think it's cheaper. I think if not for profit hospitals can adopt some of the fiscal restraints that for profit hospitals have, it would be a valuable thing to do.

But keep that savings as opposed to giving it out to shareholders. But you know this hospital was with a joint venture for two years with Columbia HCA in the late 90s, and during that time, it was a valuable experience for us. We learned some fiscal restraint that we still benefit from because we save money in areas that normally we wouldn't have.

But in a full profit system, that money savings goes to shareholders. In our system it goes back into this hospital.

LAMB: Patients, I know, a lot of times patients have spent less and less time in hospitals than they used to. You come in and have an operation, in there two days. In the old days you’d be in there a week. What happened? What changed all that?

GARRETT: Well, a lot of what happened was that insurance companies, at least with surgery, and they changed and started paying things on what's called DRG basis. You have a diagnosis, like pneumonia, and instead of paying you piecemeal, they pay you a lump sum for pneumonia. So, when that happened, there began to be pressure on the physician to get the patient out of the hospital sooner because the sooner the patient got out of the hospital, the less money that would be spent. All right? And if the patient stayed in the hospital an extra two days, then any part of the profit that might be present would be dissipated.

LAMB: Is that good or bad, in your opinion?

GARRETT: I think it's good. I think it has been good.

LAMB: So, we really didn't need to spend all that time in the hospital?

GARRETT: Well, a lot of times you don't know what you can get away with until you're pushed to do so. I mean, in cardiac surgery, we used to keep patients in the hospital eight days. We used to have something called seven day studies. We'd get all these x-rays and stuff on the seventh day and let them go home the next day. That was state of the art.

Now we get patients out in three or four days, and quite honestly, a lot of that was pushed from limited reimbursement, and you know if you want to have a successful cardiac surgery program, you can't spend all of the money. You've got to have enough money left over to buy the equipment and all that you need, so you have to be responsible.

LAMB: From your perspective, as you listen to this debate on healthcare, what's the worst thing you hear on a day-to-day basis? Do you hear people either people in these town hall meetings or members of Congress or wherever?

GARRETT: I guess the thing that scares me the most is just the thought of having the government, having sort of like a massive Medicare or Medicaid and having all of the inefficiencies that brings, and ending up with a system that is poor, a hospital system that’s poor and having no ability to offer really the best to our patients. That's what scares me the most.

LAMB: And why would that happen in an all Medicare or single payer kind of a system?

GARRETT: Well, the only thing I can say is that right now we lose 20 percent on Medicare admissions, and so if we lost 20 percent on everybody that came in, we'd have to do something different, and as part administrator, the first thing I would do is limit our capital budget. So, the new stuff that we buy, every year we buy $30 million dollars worth of new equipment here, that would stop. It would have to stop. We would have to lay off people because we'd have to get down, we'd have to make up that 20 percent, so the easiest way to make it up is to not buy new stuff, and that's what we do in our personal life, but when you're talking about healthcare, I mean, new technology is expensive, and the people that are driving new technology expect a return on their investment.

And if nobody's buying it, it'll just be a matter of time before nobody is making it, nobody’s thinking about it, and that's a disaster for healthcare.

LAMB: Knowing what you know about hospitals and doctors and operations, what would you tell a patient coming in the door? In other words, they're afraid, they're coming in, they've got a heart problem, whatever it is. What would you tell them about what you know? What should they do to give themselves more peace of mind, if possible?

GARRETT: You know I'm not sure, you know I think everybody needs insurance, so you know if you don't have insurance, you need to get insurance.

LAMB: What if you can't afford it?

GARRETT: Well, I think – I'm not a politician, but there’s something to be said about insurance reform and making insurance more competitive so that even people that don't have a lot of money can have some insurance. What you don't want is to happen to someone, and everybody can get care, OK? You can get care. The problem is someone who doesn't make a lot of money and doesn't have insurance, they're responsible to pay for the bill that they got for that care. That's the problem, paying for it.

You know the only person that ever asked me about how much something cost is someone who has money but no insurance. They want to know what's it going to cost because they're going to write a check for it.

Somehow we all need to feel some of the pain of other than writing a check for the insurance company. We need to feel that cost issue. But I do think there needs to be insurance reform, and I think everybody needs insurance, but I would start with trying to make there be more competition between insurance carriers so that there's affordable insurance.

LAMB: Who';s your biggest competition in the hospital business?

GARRETT: You mean what other hospital?

LAMB: Yes. I mean, do you feel competition?

GARRETT: Absolutely. You know in our primary service area sits INOVA, and INOVA is our biggest competitor. They are in the area that we serve our patients, and so they would be our biggest competitor.

LAMB: So, when you go home at night, you hook up with your wife, Mary, a pediatrician, what's the difference in your two lives? You're a surgeon, a heart surgeon, she's a pediatrician, and when you talk about your day in medicine, what's the difference in the two of your perspective?

GARRETT: Well, you know I'm speaking for myself, I think I have – I tend to feel more of a burden, a worry more. My wife has a lot of well patients, well babies. You know when she does have a sick child, she's totally worried at night, but that's not very typical. I think most pediatricians see well babies, and routine sort of stuff, and as opposed to my practice is I frequently have patients who are – they're pretty sick, and it's an inescapable burden. But I don't run away from, it's part of our life, and you know sometimes patients don't survive, and that's an awful – that's a terrible struggle that over the years gets harder because you have a sense that your ability should be so much greater than it was, say, 20 years ago, but you know we're not always successful.

LAMB: If you were to pass on 11 years as Chairman of the Board, if you were to pass on to somebody else this job that you have in addition to being a heart surgeon, we only have a – two minutes, what would you tell the next Chairman to worry about?

GARRETT: I would tell the next Chairman that regardless of how the – tell the next Chairman to worry about the system getting done bound and having it affect patient care, and I would encourage him not to do anything, anything that affected patient care, that made it mediocre, to keep an edge, to keep an edge of pressure on the administration, on the board, to never cut corners, to never let this thing that we've built where we give our patients the absolute best, don't let that change, and that's my biggest fear because at the end of the day, you got to pay.

LAMB: Last question. If you weren't a cardiac doctor or a heart surgeon, what would you be doing?

GARRETT: I'd be a chef. I'd be a chef. I would own a restaurant and I would work in my restaurant, and that's my second love you know.

LAMB: And your favorite food?

GARRETT: Probably Italian. Yes.

LAMB: I see you finally smiled after this interview. We're out of time.

GARRETT: Yes.

LAMB: John Garrett, thank you very much.

GARRETT: Thank you, Brian.