Thursday, 24 Aug 2017

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The Rheumatologist’s Rubaiyat: A Mug of Coffee, a Loaf of Bread and Thou Beside Me (Part 2)

In my last article, I said that coffee, not wine, would be the libation of choice for rheumatologists.  Why coffee? you may ask.  After all, the language of coffee is not dissimilar to that of wine and writers of coffee (as well as the label descriptions) use the same vocabulary and analogies as does the writing about wine. Often, from the description-with words like spice, cocoa or nuts-it is not clear whether the beverage is a Cotes-de-Rhone or an Americano. Certainly coffee is better hot than cold and appropriate for all meals although some argue that champagne can be quaffed all day long.

In my way of thinking, coffee is the right choice for rheumatologists for several reasons. First of all, its origin has appeal for rheumatologists who like history and who know that salicylates came from the bark of the willow tree and colchicine came from the leaves of the autumn crocus, remarkable discoveries that go back centuries, even millennia. Similarly, coffee started as a medicinal based on the observations of an Ethiopian goat herder named Khaldi. Khaldi noticed that his often lethargic and lackadaisical goats got frisky after noshing on some berries of the evergreen tree. Khaldi took the berries to a Muslim holy man who liked the idea and decided to make a beverage of the raw beans of a coffee tree.  Voila!  Coffee was born and the beverage was regarded as a wonder drug that needed supervision by a physician.  Imagine now if every cup of java needed pre-authorization from an insurer.  Wow!  That would be something.

The culture of coffee also aligns well with some of rheumatologists’ great skills and interests and their do-it-yourself spirit:  the development of combinations; the subtle adjustment of a regimen on the basis of some inchoate sense; and the willingness to utilize agents whose properties are not fully known. Just look at triple therapy for rheumatoid arthritis.  No one really knows how methotrexate, hydroxychloroquine and sulfasalazine work but that did not prevent landmark clinical trials using them together.  The seminal work of O’Dell and colleagues is a testament to the value of experimenting with agents, mixing and matching them in a new and untested way.  

Being tinkerers, improvisers and inventors, rheumatologists should relish the world of coffee. I will use myself as an example. In the market where I shop, I can find coffees from Kenya, Brazil, Guatemala, Mexico, El Salvador and Indonesia to name just a few.  While each comes with a descriptor that is supposed to be informative-like earthy, piquant and spicy-I just buy a few hundred grams of each. I like whole beans, medium roast since the flavors are more distinct and restraint.  Not like coffee at Starbucks where it seems that every product even with great names like Nicarauga LaRoca or Ethiopian Gedeb tastes the same because they come from beans that have been heated to the point of blackness.  

With my selection of beans-shade grown, fair trade, gently roasted- I then go home and grind up a couple of scoops with my little Braun grinder.  The grinder makes a horrible howl while pulverizing the beans into a fine powder.  I then start fiddling with blends such as a two-to-one mix of Burundi Mpema and Honduras El Puerte. I add the mix into the filter cone of my Melitta apparatus, pour in the boiling water and let it drip.  I give the coffee a taste and then grade it in a very simple way:  1 point for good and no points for not so good.  

If the taste is not up to snuff for the next cup, I may change the ratio of the coffees or add some coffee from another country, for example, spicing up the blend with some coffee from New Guinea or Sumatra-something with the hints of cocoa that give the mocha to the java. If that does not work, I try again, this time adding something more sweet and mellow like some prized beans from the high mountain forests of Peru.

You get the picture: experimentation based on intuition, science and art. This is just like managing rheumatic disease where there are literally hundreds of ways to go, with treatment algorithms looking incredibly complicated because there is no simple way to display the variety of approaches to manage arthritis. If, when treating a patient with rheumatoid arthritis, increasing methotrexate doesn’t work, I can add 5 mg of prednisone and, if synovitis persists, I can boost the dose to 7.5 mg or maybe I can split the dose or maybe I can go the triple therapy or maybe I can try a TNF blocker or maybe a co-stimulatory blocker.  Or maybe there is coexistent fibromyalgia in which case I can try some nighttime amitriptyline or maybe a dose of SSRI.  

The challenge of finding just the right regimen for someone can be great-although very satisfying then you succeed-and, if you get it right for Ms. Jones, it might not work for Ms. Smith. In more cases than we would like to admit, we are not quite sure how we came up with a combination that was so good.  

Every so often, my coffee market starts selling a new coffee from a special plantation. So, of course, I try it, first a little on its own and then I start with the mixing and I find a truly fantastic blend. Alas, I do not know the actual composition since my coffee container has remains of all sorts of different grinds in amounts that could never be determined.  While a winemaker at a winery could do such experiments-add a little Merlot to soften the cabernet and then add a dollop of syrah to boost the color-such options are not open to the wine drinker at home the way it is for the coffee drinker. Blending of bottled wine at home is against the creed. It would be downright sacrilege. I cannot imagine that anyone would add a shot of an inky fruit Languedoc to a classified St. Julien even if would pep it up and give it some zest.

As a field, rheumatology is going to see unbelievable experimentation as new drugs get approved and are incorporated in new and perhaps unexpected ways into an armamentarium that is already very large and diverse. While wine making, of course, has elements of the endeavor-new varietals as well as fermentation and viticulture techniques abound-that opportunity is open to only a few. The blending of coffee and its consumption is open to everyone and has an apt analogy to our work in the clinic.

As Howard Schultz, the founder of Starbucks wrote, “Coffee doesn’t lie. Every sip is proof of the artistry that went into its creation.” So too, the treatment of rheumatic disease by rheumatologists involves artistry in the creation.

So, dear colleagues, the next time you have a choice-drink someone else’s wine or create your own blend of coffee-I say stay true to your calling. Be an artist. Be a creator. Devise something new in the kitchen just as you do in the clinic and make it better each time.

For my part, I would like to embellish the famous words of the great theologian Martin Luther who said, “Beer is made by men, wine by God,” and add “and coffee by rheumatologists.”  

Cheers, friends, and I’ll drink to that.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

David Pisetsky, MD, PhD is Professor of Medicine and Immunology, Duke University Medical Center and Chief of Rheumatology, Durham Veterans Administration Medical Center. He received his BA from Harvard College magna cum laude in 1967 and his PhD and MD degrees from the Albert Einstein College of Medicine in 1972 and 1973. He was then an intern and resident in Internal Medicine at the Yale-New Haven Hospital from 1973-1975.  From 1975-1978, he was a clinical associate at the National Cancer Institute. He joined the faculty of the Duke University Medical Center in 1978 as Chief of Rheumatology at the Durham VA Hospital where he has remained since. He served as Chief of Rheumatology and Immunology at Duke from 1996-2007. Dr. Pisetsky has conducted basic and translational research in the field of autoimmunity, focusing on the pathogenesis of systemic lupus erythematosus (SLE) and the immunological properties of nuclear macromolecules, including DNA.  More recently, he has investigated the immune activities of HMGB1, a nuclear protein with alarmin activity, as well as microparticles. These studies have provided new insights into the translocation of nuclear molecules during cell activation and cell death and the mechanisms by which cell death can influence innate immunity.  In 2001, he was awarded the Howley Prize from the Arthritis Foundation for his work on the immune properties of DNA.  Dr. Pisetsky has had grant funding from the NIH, Veterans Administration and foundations. He has published over 375 articles, reviews and chapters and has edited several textbooks and volumes. His essays and narratives have appeared in JAMA and Annals of Internal Medicine.  From 2000-2005, he served as Editor of Arthritis and Rheumatism and, from 2006-2011, he was the first Physician Editor of The Rheumatologist. In 2016, he was awarded the ACR Presidential Gold Medal - the highest award the ACR can bestow in recognition of outstanding achievements over an entire career. He has received a number of awards for his writing. He is currently the President of the United States Bone and Joint Initiative.


Rheumatologists' Comments

Thank you, David. I very much enjoyed this, especially as a committed coffee enthusiast. In addition to the varieties, there is the "white wine- red wine" equivalent in coffee, arabica and the much neglected but often superior robusta., introducing another set of important variables.. There are many songs about wine; coffee seems less often to be the subject of the muse.The Prairie Home Companion found a way to recognize coffee with this jingle: https://www.youtube.com/watch?v=agusq6xfefI "Smells so lovely when you pour it You will want to drink a quar’t Of coffee. It’s delicious all alone, it’s Also good with doughnuts. Black coffee Coffee stimulates your urges It is served in Lutheran churches Keeps the Swedes and the Germans Awake through the sermons Have a pot of it today I’m sure you’ll say it’s awfully Good coffee." Eric Matteson
Dear David Your erudite thesis, while a well thought out hypothesis, is not evidence-based and I fear would suffer if experimenation were applied. Rheumatologists I dare say are not monochromatic in their tastes any more than in their practices. Tea for some, beer for others and coffee of course to keep them going in their challenging days. However, none of those quaffs can be accused of being "intelligent" like the delicious whites of Friuli or "complex and intense" like a pinot noir. Give me a delicious meal created by an inventive cook - who might also be a rheumatologist- and complement it with a bordeaux from a French chateau. I can then have any old strong black coffee to keep me awake when I drive home. IN VINO VERITAS! Fondly AW