Saint Alphonsus surgeon shares career highlights, need for health care workers

Dr. Robert Farivar watched as his father had a heart attack at the age of 39 when Farivar was just 16. That incident helped him decide what career he would eventually pursue.

Now, at 61, Farivar, the chief of cardiothoracic surgery at Saint Alphonsus Regional Medical Center in Boise, has led the department to earning a national three-star rating award for aortic valve replacement surgery.

It’s a monumental feat that reaffirms the dedication the doctor and hospital have to its patients. Though his daily schedule is sometimes nonstop, Farivar took a few moments to meet with Idaho Business Review Editor Marc Lutz and discuss his career, treating patients and his interest in technology.

This interview has been edited for clarity and length.

Marc Lutz: What led you to a career as a cardiothoracic surgeon ?

Robert Farivar: My dad had a heart attack in front of me when I was 16. He was 39. And I remember him falling on the ground. He’s a doctor, a gastroenterologist. And I asked him what happened and he said, “I fainted.” I said, “You didn’t faint with your eyes open.” I called my mom, we put in him in a car and we sent him to the hospital. Then, 10 years later, he’s 49. He had a coronary bypass. He’s 80 years old and doing well. I was planning on being a doctor, but you have to decide what kind of medicine you’re going to go into. So, I went into something I felt was very practical and very hands-on.

ML: What led you to practice in Boise and where did you come from?

RF: My wife and I wanted to have kids and she’s from Vancouver, British Columbia. She wanted to be closer to home but not too close. We have a 14-month-old and we wanted to be closer to British Columbia. Additionally, I knew the former medical director here. I’d met him in 2015. So, I knew a little bit about the program. I started looking in the early days of COVID in 2020, and I started here in January 2021. I’m a Bostonian, but I’ve worked in a lot of places. I’ve worked at University of Iowa, University of Pennsylvania, Minneapolis Heart Institute, and HCA East Florida. I have most recently come from HCA.

ML: During the span of your career, what changes have you seen in cardiac medicine and surgical techniques?

RF: A big change is the evolution towards more structural, which is cardiology-driven procedures. For example, TAVR ? trans-aortic valve replacement ? has really changed a lot of aortic valve replacement so that many elderly patients are [treated] using TAVR. During that timeframe also stents have really become quite popular for coronary disease. There’s this trend towards technology moving some procedures from the surgery space to the cardiology space. That’s a big trend. That’s also coming up for mitral valves, different valves in the heart. They’re getting more with structural.

And a trend that’s kind of fascinating is the cases have gotten much more complicated, really. There’s a lot of worry that cardiac surgery would go away. And that hasn’t happened at all. Cardiac surgeons are very, very busy now. And part of that is the patients are living longer. It’s more comorbidities. And as many of these procedures are done structurally, more patients come in to get them done structurally but can’t be done structurally. So, they’re passed off to the cardiac surgeon.

In general, there has been a trend towards more complex surgeries, more older patients, more re-operations that are occurring, more surgeries that wouldn’t have been entertained in the past, complex aortic surgery, for example. There’s definitely a trend towards complexity. Then there are other technologies that have come along, for example, the treatment of atrial fibrillation ? that irregular heartbeat ? that’s very common. There’s also a trend towards repairing valves, for example, more repairs of mitral valves occurring. I think it’s been a stepwise evolution of complexity.

What’s really fascinating is, as we’ve gotten more complex, our outcomes have gotten better every year, and the Society of Thoracic Surgeons database, the patients are sicker than the previous year. And every year our outcomes in terms of morbidity and mortality are better than previous.

ML: What are some of the more common heart problems that you’re seeing locally?

RF: The most common call we get is still for coronary disease, which is blockages of the vessels that feed blood. I am a specialist in valve disorders, so I see a lot of aortic valve disease, mitral valve disease, tricuspid valve disease, combined valve disease. But we also do a lot of aortic work, not just the aortic valve, but the ascending aorta. Really a profound amount because, frankly, I don’t think anybody else in the state is doing much of it.

We also see a lot of oddball stuff like surgery for hypertrophic cardiomyopathy, and that’s the disease where athletes die suddenly on the field. We have a lot of atrial fibrillation surgery as well.

One of the nice things about my practice in Idaho is it’s very diverse. Most places where I’ve worked, you really become an expert. I’m at the mid-stage of my career, so technically, I’m probably the strongest I will ever be. I get to do a lot of very complex cases that bring a lot of variety to my day here. I’m really busy, really busy. I do about 350 to 400 hearts a year.

ML: How did you and the team achieve the three-star rating? Does it come down to responsiveness?

RF: No, I think it comes down to statistics. It’s a statistical measure. The Society of Thoracic Surgeons is the most highly respected database in the world for health care. It’s a database that senators and congressmen talk about. And it’s been validated now for 40 years with approximately 300,000 patients a year going into it. Essentially all the programs in the United States and Canada report to it. They report, I think, on every patient we have ? 265 data points ? and the data points are demographic data points such as age, height, weight, gender, etc. Then there are [other] data points: How long would it take you to do the case? What size valve did you do? And then a whole wealth of other points. Once they’re entered into that database you end up either being one star, two star, three stars. You have to be in the top basically 4% of programs to be three-star, and you also have to have a high enough volume to justify meaning. If you do 10 of them and you do it perfectly, that’s not getting you in there. You have to do hundreds of them. And then you’re indexed against every other program that submits data. When you submit your data and they compare it, they curve it to every other program in the United States. It’s actually very hard to achieve three-star status.

ML: What are some of the more challenging aspects of your career?

RF: I think the labor pool in Idaho is challenging. There aren’t as many advanced practice providers and senior nurses as we’d like. There aren’t as many intensivist people who come and care for these patients with us. For example, there’s really not training programs in Idaho. We don’t have a lot of students then wanting to stay near the place they have retrained. I think Idaho has one of the lowest per capita health care providers in the United States. That’s a real challenge. How do you recruit people, especially as the population grows?

ML: What are the rewards you get from this career?

RF: I think the biggest reward is on a daily level. I feel like something I’ve done using my manual dexterity and skills over the years has helped someone in a palpable way. That is very satisfying. And in fact, days that I don’t do surgery, which is rare, I don’t sleep as well. I definitely sleep better whenever I do surgery.

ML: If you weren’t working in this field, what vocation would you like to try?

RF: I was very interested in GPS systems. When I was 18 years old, I started designing a way in the car, so I just detected where you were and where you’re going. This was before the satellites. I thought of scanning all the street maps and then using an algorithm to get you there, and then when you actually made that turn, there would be a little button on your steering wheel, and you press it and it would tell you the next place to go to turn. And I remember telling my dad about this idea and he said, “Get rid of this idealism. If you do this, you’ll never be a doctor.” But probably be CEO of Garmin (laughs).

The other the other thing I would probably do is plastic surgery. Because there’s really two kinds of surgery. There’s a kind where you take something out of somebody, like gallbladder or appendix. Whereas the other thing is you build something inside somebody. There are very few surgeries that actually build. Cardiac surgery does it, vascular surgery does it, plastic surgery does it and orthopedic surgery does it. You’re actually building something inside someone. And I think that’s what I like about cardiac surgery: You’re building something inside that helps them live longer.

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