Lately, Bill Frist, M.D., has taken to issuing medical opinions based on videotape reviews. In a new twist on the medical house call—the Senate call, maybe?—the politician in charge of Congress' upper chamber last week said he watched "an hour or so" of video of brain-damaged Floridian Terri Schiavo and then concluded that years of medical and judicial reviews were wrong: Schiavo is not in a "persistent vegetative state." Armed with his long-distance brain evaluation, the heart surgeon rose in a late-night session of Congress and proclaimed that it was the duty of the U.S. Senate, under his leadership, to keep Schiavo alive.

"Congress has been working nonstop over the last three days to do its part to uphold human dignity and affirm the culture of life. I am pleased to announce that the House and Senate Republican leadership have reached an agreement on a legislative solution," he said Saturday. "I am pleased with our progress thus far, and I am committed as leader to see this legislation pass and give Terri Schiavo one last chance at life."

To many, the move smelled more of hypocrisy than Hippocrates. "It'd be hilarious if it weren't so grotesque, how his presidential ambitions and pandering to the right wing is clashing with his life's work," one Democratic strategist told The Washington Post. (Not to mention that the GOP is all about states' rights—until a state does something they don't agree with.) Others piled on, pointing to a memo circulated among top Republicans that called the Schiavo case "a great political issue" for snaring conservative Christian votes. Frist denied knowledge of the memo, and his chief of staff insisted the majority leader's intervention in a swing state pro-life case had nothing to do with his increasingly apparent presidential ambitions. "His interest in this was sparked solely as a medical and human rights matter," Eric M. Ueland told the Post. "It's time for people to take off the 2008 rose-colored glasses and see Bill Frist for who he really is."

That would be more persuasive if the good doctor hadn't already parsed words for political gain on an issue of life and death. In December, appearing on ABC's This Week with George Stephanopoulos, Frist refused to say that HIV cannot be spread through tears and sweat—presumably because he would be contradicting a federal education program that's particularly popular with conservatives. "I don't know..." he told Stephanopoulos, when asked if it could be transmitted through sweat and tears.

"You don't know?" replied an incredulous Stephanopoulos. Frist stammered a few more noncommittal responses before conceding, at the end of the interview, that "it would be very hard" for someone to contract HIV-AIDS from sweat or tears. Forget that the Centers for Disease Control and Prevention say the virus has never been transmitted that way; when votes are at stake, science becomes malleable. Let's hope leeching never becomes de rigueur on the religious right.

What makes the Schiavo grandstanding even more distasteful is that Frist hasn't expressed the faintest outrage about the fact that 323,000 Tennesseans are about to lose their health insurance, which will surely mean a swifter death for many of them. As one keen Scene reader pointed out this week, this "selectively compassionate senior senator" has yet to speak out so "forcefully" for his own constituents. The real life worth saving, apparently, is his political life.

Few people, then, were very surprised to see him show up in Manchester, N.H., a few weeks ago (with First Lady aspirant Karyn in tow) to deliver a nationally televised speech to Republican loyalists. Between that address and one in Keene, N.H., Frist managed to make some very candidate-like statements. "My goal is to move America forward in a way that serves the cause of freedom," he said. "The mission is to secure a safer, secure a healthier and more prosperous future for the next generation." (His goal? Surely he meant to say "the Republican Party's goal.") Couple rhetoric about "freedom, democracy and liberty" with a "Road to the White House" logo in the corner of the TV screen, as C-SPAN did, and you've got yourself an early Republican presidential candidate, though not a subtle one.

Trouble is, Frist plans to serve as Senate majority leader until his second term expires in 2006. His is a job that demands compromise and negotiation, the diplomat's ability to build consensus and share credit—the exact opposite traits of a self-promoting presidential candidate. But Frist hasn't shown much willingness to compromise, instead opting to grandstand on issues that appease a hungry, right-leaning base. In April, the Senate may face a virtual shutdown—the so-called nuclear option—if Frist tries to rewrite the body's rules to keep Democrats from filibustering judicial nominees. Should a crisis-averting compromise be reached, it may only be because the majority leader can't scare up enough Republican votes to change the rules.

Frist's colleagues praise his good bedside manner—the medical metaphors never stop—along with his unswerving focus on whatever issue is before him. But what will happen to the Senate now that Frist has so clearly focused his eyes on the White House? Can a presidential candidate lead Congress' collegial body?

In many ways, the man is torn among difficult constituencies: the 99 senators who expect him to run the Senate with their divergent interests in mind, the White House that propelled him to the top job and whose political agenda he has pushed almost unfailingly, and the American public—including right-leaning Republican primary voters—that he hopes will elect him president in 2008. For the next two years, the wealthy 53-year-old surgeon must walk a tightrope between the White House and the Senate, all while carefully balancing his hefty presidential ambitions.

To understand Frist's particular challenge, you have to understand a few things about the U.S. Senate. It is deeply anti-majoritarian, so consensus-oriented that it operates under "unanimous consent," the idea that to get anything done, everyone has to be OK with doing it. Frist must convince his colleagues that they'll gain something from whatever business takes place on the floor; he has to throw enough bones to senators in the minority that they'll play along with the Republican agenda in an effort to score some cheap political points.

"Sen. Frist's job is a lot like that of a university president," says Tennessee Sen. Lamar Alexander, sporting a sweater vest and sitting in a wingback chair in his spacious Washington office. (Put a pipe in his hand and he'd have perfected the college president look himself.) "It looks like he has a lot of authority, but he really doesn't; it's mostly persuasion. Because he doesn't get up and say, 'We'll do this.' He gets up and says, 'I ask unanimous consent that we open the senate tomorrow at 9:15 and then move on to the bankruptcy bill.' If one single senator says no, we don't."

Frist has to employ the art of coalition-building, explaining to his colleagues exactly how something is in their (arguably) enlightened self-interest. Someone once described the Senate as 100 small businesses that share a common ventilation system, and it's the majority leader's job to make sure that everyone gets along just well enough to stab each other in the back.

Which can be hard when you're quite obviously stabbing your own colleagues in the back. "Many Democrats won't forget that Sen. Frist went to Sen. Daschle's home state and campaigned against him," says one Democratic leadership aide of Frist's 2004 decision to break with majority leader precedent and campaign against minority leader Tom Daschle in South Dakota. In addition, Frist directed huge sums of money to Daschle's opponent, John Thune, through the leader's political action committee, Volunteer PAC.

Democrats also haven't forgotten Frist's leadership of the Republican senatorial campaign committee in 2002, the year the GOP unseated disabled veteran Max Cleland by questioning his patriotism. They still bristle over that campaign and, more recently, Frist's Senate floor character assassination of former counterterrorism chief Richard Clarke, who testified before the Sept. 11 commission that the Bush administration—including Clarke himself—could have done more to prevent terrorism. The maliciousness of Frist's attack on Clarke upset Republicans and Democrats alike. "It's like he was handed a script from the White House," one senator said at the time. More recently, a Democratic aide told me it was "scary" how readily the majority leader "did Bush's bidding." With Frist, it seems, politics can be especially ruthless.

Recently, Frist's nuclear brand of politics has been on display again as he's marched the Senate to the brink of shutdown over the issue of judicial nominations. Republicans are upset that Democrats have threatened to filibuster Bush's federal court nominees, effectively preventing them from being voted on by the full Senate, a roll call that most nominees would surely win. Democrats maintain that they're merely exercising the minority party's right to be heard under the Senate's time-honored rules. But the GOP, led by Frist, has threatened to change the rules so Dems can no longer filibuster judicial nominees, a so-called nuclear maneuver that would surely prompt the minority party to bring all Senate business to a halt. As a result, Congress' collegial body is fiercely divided along party lines these days.

In fact, Republicans who sought bipartisan compromise have in some cases been punished. When Pennsylvania Sen. Arlen Specter, who was about to assume chairmanship of the judiciary committee, suggested last November that anyone who opposed abortion rights could not be confirmed as a federal judge, conservative groups went ballistic. Frist met with Specter and forced him to renounce his blasphemous statement publicly in order to be appointed chair of the committee. He did.

Around Washington, particularly in Democratic circles, people say the Specter spectacle was an example of the far right flexing its political muscle after an election in which it had prevailed, and a presidential wannabe caving quickly to its pressure. Although it may have served Frist's—and the White House's—long-term political interests to rake Specter across the coals, it wasn't good for teamwork within the Senate. "A lot of being a leader in the Senate is about building relationships," says a 13-year veteran advisor to one Democratic senator. "He's going to have to make some choices there as to if that's the best way to run the Senate or to run for national office. I would say it's probably in the interest of someone running nationally to be more confrontational in his style."

"Any time he goes to a room to negotiate a bill, people are going to be wondering if he's really negotiating, not running for president," says another Democratic leadership aide.

As the No. 1 Republican senator, Frist has the platform from which to launch a bid for the presidency. In his role as majority leader, it's his job to broker compromise, but to curry favor with conservative primary voters, it may be smart for him to take much more ideological positions rather than pragmatic ones. (Which is ironic because Frist has never been regarded as a particularly ideological guy. The multimillionaire didn't even vote until he was 36.) Can he wear two hats at once?

Veteran senators from both sides of the aisle, ever diplomatic, say they're not worried. "I like Bill Frist," Sen. Edward Kennedy tells the Scene as he shuffles into a Capitol Hill elevator en route to the basement, noting that he's enjoyed working with Frist in the past on health care issues. Kennedy has had dozens of years to master the senatorial soundbite, in which backhanded jabs at political opponents are hidden within mostly flattering comments. For example, he says he doesn't worry that Frist's presidential ambitions would influence the Senate's ability to do business, before adding a sly afterthought: "I know some do, but I don't."

Sen. John McCain, who like Frist is regarded as a Republican presidential contender, doesn't take the bait either. "He's too good a man" to let his presidential candidacy get in the way of his Senate leadership, McCain says after emerging from a luncheon for Republican senators. Of course, McCain, a favorite among political moderates, has been boosting his national profile recently with renewed campaign finance reform efforts, so he's not throwing any stones at Frist. (The straight shooter of American politics, as McCain has come to be known, declines to tell a reporter what he really thinks about Frist over a drink, compliments of the Scene. But we tried.)

For his part, Alexander concedes that running for president might make Frist lean right but says he doesn't think it's likely. "I think he'll be judged about how effective a Senate leader he is, and in a body that operates by unanimous consent, you don't usually get very far by confrontation," says Alexander, adding that the best thing Frist can do for his political future is lead well and enjoy his high profile.

"If you project ahead about who has the intelligence and who has an interesting story being a medical doctor and doing missionary medicine in Africa, who's right on the issues, who has the ability to raise money and who has the energy to take on running for president, it's almost impossible to think of a 2008 race without Bill Frist right up at the front of the pack," Alexander tells the Scene. "If he decides to run."

So far, he's planning to do just that, according to a few Republican insiders with connections to the senator. They say he will return to Tennessee after his term expires in 2006 and live in his family's completely rebuilt West Nashville mansion, where he'll officially make up his mind. But for now, they say, the course is set for the White House.

"If I had to guess, it'd be my opinion there's one chance in eight that he might not run," says a national Republican fundraiser who spoke to Frist about his presidential aspirations a few weeks ago. (This source puts the odds in favor of Frist running at 80 percent. Don't try to reconcile the numbers.) A Nashville-based national Republican strategist agrees. "He would have to do something affirmative to get out of the race rather than to get in," this person says. "He's on the track." Still another veteran of national Republican politics jokes that Frist's trip to New Hampshire had nothing to do with its first-in-the-nation primary election and his plan to run for the presidency. "This time of year the crisp, cool air clears the brain," he says. "A lot of people go up there for therapy."

One way to tell Frist has set his sights on bigger and better things is to chart his deep-pocketed political action committee, VolPac. In recent weeks, sources say, VolPac has hired staff and continued to raise money—which would be pretty odd if Frist were a lame duck incumbent and not a presidential candidate. "VolPac is still functioning aggressively, which is a pretty good sign for a guy who's going to leave office shortly," says one Republican operative. "That's a pretty good sign he's looking at things beyond 2006." In addition, Frist's PAC continues to do hundreds of thousands of dollars in direct-mail business with Ted Delisi, a Texas political consultant with ties to Karl Rove. Anything connected with Rove, the political kingmaker, gets people talking.

A run for the presidency is all about winning political loyalty, and Frist's generous fundraising for Republican colleagues over the past few years is expected to pay dividends. "VolPac directed a lot of money to a lot of people," one strategist says. "In the event that Frist makes a move for the presidency, he's going to have a lot of people who remember those favors." Meanwhile, President Bush will no doubt remember how unswervingly his hand-picked majority leader implemented his agenda in the Senate. Some observers predict that the administration will do a lot of behind-the-scenes work to help Frist's candidacy, but officially Bush and company will be neutral—at least for a while.

A couple of sizeable obstacles stand between Frist and the presidency. One is his utter lack of charisma, the calculating way he looks through people, not at them, and his awkward, robotic demeanor. It has evoked unfriendly comparisons to Al Gore and John Kerry, even among Republicans. "I think he has improved dramatically since he's been in the U.S. Senate," the Republican fundraiser says of Frist's stump style. "I think he still has a ways to go. But keep in mind, a lot of people who won the presidency didn't have much charisma." That's cold comfort for the doctor with the chilly demeanor, but Frist is rumored to be taking charm lessons.

What's most perilous about Frist's situation is the bind it puts him in between the president's agenda and his own. Just three weeks ago, the majority leader performed an unceremonious about-face on Social Security reform, abruptly saying it would be an immediate priority after having just said he wasn't sure if the Senate could get the president's plan passed this year. He finds himself in a similar situation over the judicial nomination issue, on which he may be forced to cave or compromise because he can't line up enough Republican votes to change Senate rules.

Already, the majority leader reportedly feels the political strain of his job. "Sometimes as majority leader you have to take positions in support of the president that don't help advance your political concerns," the Republican fundraiser says when asked if Frist told him what worried him most when looking ahead to 2008. Specifically, the fundraiser says, Frist was worried about Social Security.

"If he continues to pass bills that are a part of the president's agenda, he's going to score some major points with the White House. I think you can see that he's doing that now," says a senior Republican staffer. But, he warns, Social Security privatization is dead in Congress—"Foreign policy is the new Social Security"—and Frist last week expressed a willingness to compromise with Democrats on the judicial nomination issue, both of which may be signs he's unhitching his wagon from the Bush White House.

As the nuclear option plays itself out next month and Bush's Social Security reforms die a slow, public death, Frist may be forced to distance himself from the lame duck White House and come into his own as majority leader—that is, if he wants to keep his political options open. It will be the greatest test to date for a man who has until now run the Bush administration's satellite office on Capitol Hill. At the same time as he's stepping away from the party's public leader, Frist must take strong party line stands to shore up support and build name recognition among rank-and-file conservatives.

How to seem like a principled presidential candidate while building the legislative record of a pragmatic majority leader? How to grandstand without ruffling colleagues' fragile feathers? How to strategically embrace and distance a popular but polarizing president? These are among the difficult political dilemmas Bill Frist must navigate in the last two crucial years of his career as Republican leader. They say the guy's smart and a quick study, but he's taken on an entirely new challenge in his bid for the presidency. Moving from the Capitol to the White House may be Dr. Frist's trickiest transplant yet.