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

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.