Monday, March 8, 2010

It isn’t always as it looks—the case of the savory cheesecake

In medical school we are always taught the classic presentation, the triad of symptoms, and the pentad of problems when we try and diagnose a disease. To uncover pathology is simply pattern recognition. For example when a patient presents with appendicitis, we expect to find pain in the lower right part of the abdomen, a fever, no appetite, nausea, and vomiting.

Unfortunately, medicine is not so simple. As it turns out, the classic presentation is probably less common than the atypical presentation. Many of the physical exam signs that we rely on to make a diagnosis are not reliable. In the excellent series “The Rational Clinical Exam” published in the 90’s and early 2000’s by JAMA, the authors reviewed literature focusing on the utility of different physical exam signs.

When a patient thinks they have strep throat, for example, the only signs or symptoms that help rule in strep throat are presence of exudates in the throat and recent exposure to somebody with strep throat [1]. Having a sore throat or fevers, the “classic presentation” is not predictive of strep infection, although fever can help secondarily guide the diagnosis in the absence of other signs.

Conversely, oftentimes what appears to be a classic presentation of one disease turns out to be something else, or is labeled idiopathic (another way of saying that “We have no idea!”) One of the hardest things I had to cope with in the clinical years of medical school was how many times there was simply no explanation for why somebody was sick. After watching so many episodes of House, I had assumed that everything would culminate in the diagnostic climax of a happenstance realization: “Did you say cheese? Hmmmm, as the resident pensively braces her chin. It must be Kawasaki’s disease!”

What’s true in the hospital can also be true in the kitchen. Things are not always as they seem. This recipe is for a savory cheesecake. Perhaps upon initial examination it appears to be dessert. But look closer. That green layer isn’t pistachios or mint. It’s spinach and chard. On top is a layer of red peppers and tomato, on top of that a layer of roasted yellow pepper, carrot and saffron. It isn’t dessert, but dinner! The beauty of the savory cheesecake is that it can be eaten for breakfast, lunch or dinner, hot or cold. It can be served as an appetizer or a main course. To warn you though, this is not light on calories, time, or dishes. It is however, rich, filling, and extremely appealing.

It isn't always as it looks--the three layer savory cheesecake (recipe cont...)

It isn’t always as it looks—the three layered savory cheesecake

10 inch springform pan
2 lbs (four packages) cream cheese softened and cubed
11 oz goat cheese (if you only have 10, or 8 it’s ok to fib)
16 oz ricotta
1 red pepper, halved and seeded
Hand-full fresh chives, finely chopped
1 tsp salt
Freshly ground black pepper
5 eggs
2 orange or yellow peppers, halved and seeded
4 cloves garlic, crushed
2 sprigs thyme, finely chopped
6 leaves (half a bundle) Swiss Chard
1 10 oz package frozen spinach
1 carrot, grated
¼ tsp saffron soaked in 1 tbsp warm water
½ tbs paprika
3 oz (half can) tomato paste

For crust
¼ cup (1 stick) unsalted butter
¼ tsp salt
1 cup flour
Between 2-4 tbsp ice water

To make crust. Preheat oven to 400. With pastry cutter, cut butter into flour until it is pea shaped. Add water slowly just until it comes together in a ball. Mix with hands briefly, just enough to bring ball into dough. On floured surface, roll into ~10” disc with rolling pin. Put in springform pan. On top of dough, put sheet of foil and beans, coins, or pie weights. Bake for 10 minutes, remove foil, and bake for another 10 minutes or until golden brown.

To make cheesecake. Under broiler, roast peppers skin side up until black and charred, about 20 minutes. After done broiling, reduce oven temp to 375. Peel and dice. Cut swiss chard into small pieces and sauté on medium heat with a splash of olive oil until wilted. Defrost spinach in microwave. Squeeze out as much water as possible from chard and spinach.

With mixer, beat together cream cheese, goat cheese, ricotta, garlic, salt, herbs and pepper until fluffy. Beat in eggs one at a time, until incorporated. Divide mixture into 3 equal parts.

In food processor, take 1/3 mixture and pulse with spinach and chard until well incorporated. Pour gently into springform pan on top of crust. Clean out food processor, add next 1/3 cheese mixture and blend with tomato paste, paprika and red pepper. Pour gently on top of spinach layer. In food processor, add saffron with water, carrot and orange/yellow peppers. Pulse until smooth and pour on top of tomato layer. Bake cheesecake at 375 until center moves slightly but sides are golden, about an hour to 70 minutes. Cool on rack for 1-2 hours and refrigerate, or serve at room temp.

My cheesecake cracked like stink, and the top layer was too wet and infiltrated. I am sure there are ways to make this not happen, but I kind of liked it. It made it imperfect, as it should be.

1. Ebell, MH., et al. “The rational clinical examination. Does this patient have strep throat?.” JAMA : Journal of the American Medical Association, v. 284 issue 22, 2000, p. 2912-8.


  1. This post was so charming. I can't think of a better word. Quite timely too, as I recently read a post from another med student about how 'uncommon' patients are like Rubik's cubes with the stickers stuck on wrong or that don't twist properly ( Food can seem formulaic, with recipes and whatnot to follow, but the final product is of course more textured and subtle than we think, just as people are. You write beautifully. Keep up the good work!

  2. Elizabeth. Thank you for you kind words. I think this comment is much more intelligent than anything I could write. You keep writing too!