ROCHESTER – As a young physician, Gianrico Farrugia admired Mayo Clinic's Plummer Building, a historic landmark with massive bronze doors and a soaring bell tower that projects the enduring prestige of the clinic.

His reverence, however, didn't extend to its very peak. The top, he noticed in the late 1980s, "had this really ugly aluminum cylinder."

Fifteen years later, as the Plummer Building underwent a major restoration, Farrugia became obsessed with the chance to make a change.

He uncovered proof that when the landmark first opened, it was topped with a lantern-shaped cupola — not the metallic cylinder. The photo startled old-timers and helped persuade clinic officials at the last minute to place a recreated cupola at the building's apex.

"Every weekend, I would come into the archives, put on a pair of white gloves, to find the photo," said Farrugia, who years earlier had heard a tour guide mention the cupola. "One of my characteristics is I file things, and I bring them up at the right time."

Farrugia is now bringing the same approach to the top of the entire Mayo organization. After leading its Florida operation since 2015, the 30-year Mayo veteran in January became the latest chief executive at a Minnesota institution that is the state's largest private employer, with about 43,000 workers, and a magnet for patients from around the world.

He takes over at an unpredictable moment in health care. New players including Amazon are vowing to upend the system. Prominent presidential candidates are debating fundamental reform, including a push for Medicare for All. Employers continue to demand more cost-effective health care.

Against all this, the clinic has a relatively strong market position driven by its reputation, said Daniel Steingart, a vice president with Moody's Investors Service. "More people want to go there," he said, "than they can possibly accommodate."

Farrugia thinks Mayo's strengths position it to attack a wide-ranging agenda with the potential to profoundly change health care.

Artificial intelligence is beginning to change medicine as powerful computers spot patterns and trends previously hidden in millions of patient records. Farrugia says Mayo — with its trove of patient records — needs to lead the effort.

At the same time, Mayo is preparing for a health care world in which virtual visits to the doctor outnumber physical visits, Farrugia says, yet the clinic must also make smart investments in the brick-and-mortar centers that patients with complex medical conditions require. To ensure quality patient care, Farrugia says a priority is to restore a sense of joy to the work of health care, where burnout and stress are grinding away at doctors and nurses.

There's a long to-do list. Farrugia sounds as excited for the future as he is enthusiastic about Mayo's past and present.

"For me, as a physician growing up on a tiny island in the Mediterranean, to be asked to be CEO of Mayo Clinic is profound," Farrugia says. "It's an honor. And it's something I really don't take for granted."

He adds: "We have an obligation, a responsibility, and we have the tools to transform health care from within."

From Malta to Mayo

Gianrico Farrugia (pronounced fa-ROO-jah) was born in 1963 in Malta, a small island just south of Sicily. He was the middle child in a house led by his "wickedly smart" mother and physician father. Beyond being a general practitioner, the elder Farrugia created the first blood bank in Malta and served as a diplomat.

After a short-lived aspiration to play professional soccer, Farrugia followed his father into medicine.

He attended medical school in Malta and then followed a fellow countryman in seeking advanced medical training at Mayo Clinic. Six months before leaving for Minnesota, Farrugia met a professionally trained ballerina named Geraldine. He pledged that he would return to her in Malta in a year.

Later, he phoned from Mayo to pitch the idea of marriage and a Rochester relocation. They're together today, with two adult children.

As a researcher, Farrugia's work has shown how certain cells function as pacemakers of the gastrointestinal tract. Currently, he's principal investigator on a prestigious National Institutes of Health grant that's been renewed repeatedly over the past 22 years.

Despite arriving at Mayo with relatively little experience working in labs, Farrugia sought out the most challenging topics, said Joseph Szurszewski, a research scientist at Mayo. "That told me immediately that this man was either crazy or really good. As it turned out, he was really good."

Once Farrugia completed his training, he joined the medical staff at Mayo. He performed colonoscopies and treated problems of the gut such as gastroparesis, where a muscle problem prevents the stomach from properly emptying. He co-founded Mayo's Center for Innovation, which stressed the importance of design in providing good patient care — things like re-imagining exam rooms to promote collaboration between patients and doctors.

Farrugia worked to bring genomics into clinical care as director of Mayo's Center for Individualized Medicine. And in 2015, he became chief executive of Mayo Clinic's hospital in Jacksonville, Fla.

"He works 22 hours a day and he thrives on it," said Dr. Nicholas LaRusso, a Mayo physician who co-founded the Center for Innovation. "He smiles a lot. He jokes a lot. He's very direct, which is a little unusual in some of the aspects of the Minnesota Nice culture."

A torn Achilles' tendon from an evening game of soccer helped put that work ethic on display about 13 years ago. In the moment, it "hurt a bit," Farrugia recalled.

Mayo Clinic provided great treatment, he said, but he recognized a shortcoming when his doctor said he shouldn't put more than 20 pounds of weight on the injured leg. How does a patient measure that?

Farrugia rigged a pressure sensor with lights to indicate the weight burden. To avoid missing work, he used a recliner and a computer mounted above him — keeping his leg elevated above his heart kept down swelling.

"It was my first true experience of being on the other side of health care," he said.

"It sort of has driven me to always think about, OK, now we're doing this very well; what can we do better?"

The guy in scrubs

On a Friday morning in May, Farrugia is dressed in blue, standing in a room that looks a bit like a movie theater.

The lights are down. The audience is watching real-time images from the nooks and crannies in a patient's sinus cavity displayed on a big screen.

In this operating room, Mayo Clinic physician Erin O'Brien is using a tiny medical instrument to clear sinus obstructions. A scope beams out interior images so she can see.

Farrugia estimates this is one of about 100 medical procedures he's dropped in on since becoming CEO in January. He found that making spontaneous visits to ORs and hospital units was a good way to connect with workers and patients in Jacksonville, so he's continued the practice.

Earlier this morning, when Farrugia met the woman undergoing the sinus procedure, he waggishly suggested that she would benefit from the boss' presence during the operation.

"It was extremely unlikely," he said, "but now it's impossible anything bad could happen."

Mayo Clinic's origins date to the 1880s, when doctors William and Charles Mayo joined the medical practice of their father, Dr. William Worrall Mayo. From the start, the clinic has appointed CEOs who are insiders and also physicians.

As a physician, Farrugia believes the design of physical spaces in clinics and hospitals is important to the healing experience of patients. It also lets health care workers do their jobs better.

As CEO, he's bringing the concept to Mayo's executive offices, replacing dark paneling and a hodgepodge of carpets and furnishing with open space that's meant to be welcoming. Rather than an office, he'll work at a desk in the middle of the room. And he plans to continue his research.

He calls himself a "fidgeter" who doesn't find it easy to sit still. Is that a good quality?

"There's Mayo science that shows that you are less likely to put on weight if you're a fidgeter, so that's the good part. The bad part is, as a CEO you need to be more calm, and that's something I continue to work on."

Workforce (average full-time equivalent employees, all locations) • "Upper Midwest" includes Illinois, Indiana, Iowa, Michigan, Missouri, Nebraska, North Dakota, South Dakota and Wisconsin. • Endowment figure for 2011 was for assets reported at the beginning of 2012.

Source: Mayo Clinic bondholder filings and financial statements

C.J. Sinner and Jim Foster, Star Tribune

Patients, prices

The work ahead to ensure that the Rochester-led institution emerges as a leading player in a changing health care system includes a push to "create Mayo Clinic as a platform," Farrugia says.

It's a goal best explained through examples, such as an ongoing project in which Mayo doctors developed a "bloodless blood test" that could let physicians monitor patient potassium levels at home, and thereby know when they can safely order medicine changes. To validate the idea, Mayo scientists asked a computer to analyze the clinic's voluminous set of medical records and learn whether there are subtle signs in electrocardiogram data that correlate with potassium levels.

The clinic's unified data platform includes 7 million EKG tests that have been digitized.

"We have 200 artificial intelligence projects active at Mayo Clinic right now," Farrugia said. "We see artificial intelligence as a new set of eyes, enabling physicians, patients to see things that could not be seen before."

Artificial intelligence should help Mayo improve its process of determining which patients have the greatest need for the clinic's advanced services, Farrugia said. Questions about which patients get access to Mayo — and at what price — have been controversial over the years.

Two years ago, after a Star Tribune report quoted Dr. John Noseworthy, Mayo's CEO at the time, saying the clinic should prioritize patients with commercial insurance over lower-paying government coverage in certain instances, groups such as the Minnesota Nurses Association were sharply critical. The chief executive later said he regretted the word choice.

The idea that Mayo isn't committed to treating Medicare patients is probably the "most common misconception" about the clinic, Farrugia says, noting that Mayo is treating more Medicare patients now than ever.

"For most things, we have more demand than we have capacity for," Farrugia said. "So, we have to choose. We choose complex and serious — the people we can help most — and we do that totally agnostic to payment model."

Like most marquee medical centers across the country, Mayo operates a regional network of clinics and smaller hospitals. One key difference is that Mayo's regional network spans rural areas where the economics of health care can be tougher than in big cities.

Mayo is committed to serving smaller communities in Minnesota, Farrugia said, adding that technology will help meet some challenges.

"But we also need to understand that … the highest quality is what we have to strive for," he said, "and that sometimes means making some very hard decisions of where you can realistically deliver the highest quality."

Employers and health insurers have long complained that the cost of care at Mayo Clinic is much higher than elsewhere in the state. It's to the point that, earlier this year, an employer in southern Minnesota started offering to cover travel and lodging costs for workers to undergo knee and hip replacements in the Twin Cities rather than Rochester.

Farrugia, however, insists that the perception is based on data reports that don't give Mayo Clinic credit for avoiding unnecessary costs and delivering quality. He pointed out that retail giant Walmart recently started directing employees from across the country to Mayo Clinic for joint replacements.

"Believe me, Walmart's database is pretty extensive," Farrugia said. He added: "We understand that any time we can make our care more affordable … we have a responsibility to do that."

Building on tradition

Affordable isn't a word that comes to mind when looking at the gleaming marble lobby of the Plummer Building, which was taller than any structure in the Twin Cities when it opened in the late 1920s.

Farrugia's story about the building's peak provides a glimpse of the individual initiative he hopes to inspire at Mayo, colleagues say, and how those actions can fit within the clinic's collaborative environment. Farrugia didn't have authority to alter the Plummer renovation, but he worked with colleagues to get it done.

The story also suggests a handy skill for any CEO at Mayo, even as technology reshapes the health care it provides: Propose changes that square with the clinic's past.

"There is a sense of responsibility that the Mayo brothers did something special, and we cannot mess it up," Farrugia said. "And that we have to continue to do better because … there are still so many unmet medical needs."