The entire thread can be read at Google Groups: Subject: HOUSE, M.D.: 31. "Deception" From: MDuPree@theworld.com.snip.to.reply (Micky DuPree) Newsgroups: rec.arts.tv,alt.tv.house-md Date: Sun, 18 Dec 2005 21:48:43 +0000 (UTC) Organization: The World : www.TheWorld.com : Since 1989 Message-ID: Lines: 1069 Spoilers for "Deception," 12/13/05. . . . This took me a lot longer than usual. Ordinarily, I don't get too put out by questionable medical points as long as they're internally consistent. I'll make an open query as an educated layman just out of curiosity, but if they say that drug A cures disease B, then fine, as long as they don't say the opposite in another episode or forget all about drug A the next time disease B is mentioned. But there was so much that just didn't make sense in "Deception" purely from a methodological standpoint, that I slowed down and transcribed almost every single medical discussion to make sure that the problem was them, not me. There were some really funny lines in this episode, but the particulars of the antagonism between the characters made them look stupid and amnesiac, which faults really lay with the writers. Michael R. Perry was the credited writer, and I'm pretty sure that's a new name. Christmas tree at the OTB, candy canes and stockings in the Diagnostics office, poinsettia in Cuddy's office, Christmas lights around the nurses' stations, Charlie Brown music at the end. I think they were trying to tell us something. PROLOGUE Sign on the betting shop window: Lower Yardley ??? Presumably Yardley, Pennsylvania, just across the state line, because New Jersey doesn't yet have off-track betting. Gambling is the second thing that we've seen House spend his money on. I wasn't sure how good at it we were supposed to think he is. He gave a decent rationale for betting on a jockey, but by the end of the episode, the onscreen score for diagnosing races seemed to be House:0, Anica:1. House dressed down to go to the OTB: pea coat with a mismatched button, dull-red canvas sneakers. (Canvas sneakers? When it's been snowing?) The zebra literally had stripes this week. ACT I I had trouble with the chronology on this one. The action opened with House and Anica at the OTB shop betting on daylight races in real time at Gulfstream Park in Florida when it seemed to be dark outside the shop. But they ended up at the hospital when it was twilight and House was wearing the same clothes. The easiest explanation is that the color timing on the exterior shot of the OTB shop was darker than it should have been. I assume that the Christmas decorations in the Diagnostics office were all down to Cameron, who seems to be a self-styled atheist with a sentimental attachment to Christmas commercialism. HOUSE: Hot OTB babe has grand mal and inexplicable bruising. I wonder why at no time did anyone suggest epilepsy (plus something else for the bruising) even if only to dismiss it. House took a Vicodin during the initial diagnostic conference. CHASE: "Hot OTB babe"? Obviously a working girl. Probably an STD, infection. HOUSE: No fever, no infection. FOREMAN: Alcohol abuse explains it all. Causes seizures and affects the blood's ability to clot, which causes bruising. Start her on heparin. She'll be fine by morning. FOREMAN: She's a regular at OTB. Somehow I don't see her holding down a nine-to-five and going to PTA meetings. Probably true, but how did Foreman know Anica was a regular at this stage? HOUSE: Cushing's. Explains the seizure and the bruising. FOREMAN: Not the anemia. HOUSE: So she doesn't eat a lot of meat. Interestingly, while no one got the exact diagnosis right on the first try, House immediately shot down Chase's idea of infection and dismissed Foreman's concern over the anemia, both of which ended up being relevant. FOREMAN: DIC brought on by alcohol abuse is far more likely. Usually it's House who's eager to shoot down potential zebras as horses with delusions of grandeur. Here, Foreman played that role. HOUSE: Whoa-oa. Did you just ever so subtly order me to get her medical history? FOREMAN: Cuddy put me in charge last week, so yeah. This strongly implied that this was the first case that the Diagnostics Dept. had handled since the previous week. Otherwise, the issue of just how "pretend" the new power structure was would have arisen earlier. This would also date the hearing of the disciplinary committee in "The Mistake" as taking place approximately around Dec. 5, 2005 (see time line note infra), despite internal indications in that episode that it took place on roughly Nov. 11, 2005. It was strange to me that the Cushing's in this episode had no overlap of symptoms with the Cushing's in "Heavy." On House's t-shirt: [...]THVALL[E...] CUDDY: [To House] Those licensing board folk love to play dress-up and pretend. I thought the disciplinary committee was strictly an internal hospital matter. Why would House's case have gotten as far as the New Jersey licensing board? CUDDY: [To Foreman] If there's a screwup, it's your screwup. You won't have Doctor House to fall back on. I could have understood if Cuddy was merely making Foreman sign off on everything that House did. That would just be Cuddy making Foreman do the scut work of being her proxy. But when they said that Foreman was genuinely in charge of the department, that seemed somehow off to me. I'm not an expert on hospital hierarchy, but I thought that there were a lot of hoops to jump through to be able to wield the power of an attending physician, not just from the standpoint of not upsetting the personnel organizational chart, but also from a legal and insurance liability standpoint. If there was a screwup resulting in a lawsuit, wouldn't the plaintiff's lawyer be able to make hay out of the fact that a non-attending physician was filling an attending's role? Usually Cuddy is very keen to reduce the hospital's exposure to liability. ANICA: [Reading form] How about, um, "Were you vaccinated for polio?" I think you gave me the form intended for FDR. HOUSE: You really like Teeny Tiny Mo in the fifth? ANICA: [Snatches back her racing picks.] I went four for six yesterday. You want winners, cure me first. lol. ANICA: "Are you generally satisfied with your life?" HOUSE: It does not ask that. [Takes history form. Reads. Scoffs. Sets it aside] House didn't take the medical history form seriously, and yet he's often made diagnoses that hinged on stranger points of medical history than the form was asking for. Is it really less important to know whether the patient was vaccinated for polio than to know what the patient's cat died of? ANICA: You know, I was going to ask what a respectable doctor was doing in an OTB parlor. Somehow the question doesn't seem relevant anymore. This along with the fact that Anica chose to have the seizure in front of a doctor made me wonder if Anica had somehow targeted House, either by figuring out he was a doctor when they were at the OTB, or even finding out who he was and stalking him. (Kalvin managed to look him up and stalk him in "Hunting," so it's demonstrably doable.) However, I rewatched the prologue, looking specifically for any sign that she knew what he did for a living, and didn't spot anything. I suppose she could have just chosen the OTB as a crowded area where someone was sure to dial 911, and realized House was a doctor only after he caught up with her in the emergency room. HOUSE: [To Anica] Came here without a job. That means you didn't move here. You moved away from somewhere else. I originally thought that was going to be significant, but it didn't pan out. HOUSE: [Presses her bruises.] Does that hurt? ANICA: No. HOUSE: Are you on prescription meds? Hormones? Prednisone? ANICA: I already answered that one. I think it was question number twenty-something. HOUSE: Well, yeah, and I could reach down and get it, but that would kind of spoil the whole cool move. I guess we can't say that House was getting used to the idea of having contact with a patient, since in this particular case we know that he thought the patient was hot and he was actually flirting with her during a physical exam. I was *really* surprised (and very let down) that none of the other regulars pointed out that it was Dr. Gregory "Everybody lies" House who was so insistent that Anica didn't have Munchausen's. They could have even pointed out that he violated his own dictum about not caring about the patient, so he was biased in favor of not wanting her to be faking. "What, everybody lies except for patients you think are hot?" But they didn't, because frankly, I think the writers missed it too. As set up, this case should have been depicted as a major stumble for House because he broke his own rules, but given Cuddy's glowing testimonial at the end, it was treated as just another House triumph in a series of same. I wonder, had House actually completed the lumbar puncture, would that have yielded any clue as to Anica's infection? FOREMAN: Her initial symptoms could have been caused by alcohol- induced DIC. She had a hypertensive crisis because it's been at least six hours since she had her last drink. She's detoxing. HOUSE: At the exact same moment that I'm futilely trying to give her an LP? FOREMAN: Right, an invisible tumor on her pituitary is much more likely. CHASE: What if the tumor is somewhere else? There could be an ACTH-secreting tumor on her lung or pancreas. It's consistent that Foreman wouldn't have any sympathy for someone he assumes is a member of the underclass who refuses to pull themselves up by their bootstraps the way he did. What doesn't seem consistent is that in "The Socratic Method," it was Chase who was determined to see addiction even where there wasn't any, because his mother drank herself to death. Now Chase was among those arguing against the idea. I think they should have let Cameron be the one fighting the other two on this. HOUSE: Get a pan-man scan before she dies of cortisol O.D. [Mock-pleads with Foreman.] Please? Man, that was funny. CHASE: [To Cameron] Being in charge means having to say no to House. Would you hire you for that? Right on the nose. The triumphant return of Grave Digger. Well, all one second of it. FOREMAN: [To House] You ordered MRIs for the entire maternity ward? That was really beyond the pale. How many new parents did House scare the shit out of with that one? And if House didn't have the power of an attending, then how could he march in and order tests for patients that weren't his in a completely different department? That just sounded all wrong. ACT II CAMERON: [To Anica] Doctor Foreman's overseeing your case. He thought it'd be best if I spoke with you. Foreman picking Cameron to deliver the news about the probably terminal nature of the pancreatic mass was a good decision. She's the one who's needed the most practice in this area, and she finally seemed to have that particular problem under control. However, given the writers' performance in the rest of the episode, I couldn't tell whether this was a point of characterization that they were deliberately closing the chapter on, or if they simply forgot that Cameron was the one who had trouble delivering terminal news. CAMERON: But the bigger point is ... a one-year survival rate for pancreatic cancer is less than twenty percent. ANICA: So what's the treatment? I'm not a psychiatrist, nor even a doctor, but this felt contrived. I'm surprised that a Munchausen's patient who had been at it for a while wouldn't be more skilled at giving the right kind of concerned response to a terminal diagnosis than Anica was. Wouldn't being more distraught get her more of the kind of attention that a Munchausen's patient would want? And surely there are differential diagnoses for an undisturbed affect. House thought it meant that Andie had a clot in her amygdala in "Autopsy." Why not here? WILSON: House assisting. That is funny. Too bad Foreman's going to die. LOL, but it underscored a problem that even characters who weren't involved in the org chart rearrangement could anticipate. How effective could Cuddy expect Foreman to be with the possibility of retribution at the end of the month hanging over him? FOREMAN: Anica's biopsy for pancreatic cancer was negative. You're not really supposed to mention patients' names and medical results together in front of other patients. Foreman ought to have known better. CAMERON: She's had zero symptoms since she got here. Well, not entirely true since they eventually told us that the anemia was constant. CAMERON: [To Foreman] We should check her apartment, look for medications, syringes. HOUSE: Venous sampling's easier. FOREMAN: And more dangerous. HOUSE: Not if you get caught breaking in. FOREMAN: So don't get caught -- House. Funny in isolation, but if part of the point was supposed to be that Foreman disapproves of House breaking the rules, then Foreman shouldn't have sanctioned breaking-and-entering orders here even for revenge. No one called him on it. House's license plate: New Jersey Y91 07 MOTORCYCLE I don't think they let Laurie and Morrison drive off on the bike. They didn't let us see their faces once the bike was in motion. HOUSE: How many hospitals have you contacted? Has one doctor said she's crazy? It's not Munchausen's! This REALLY didn't sound like House. For one thing, he has a history of distrusting other doctors anyway. For another, surely a Munchausen's patient sees multiple doctors for some time before finally being detected. No, there was nothing conclusive about anything Cameron had found up to this point, but neither was there anything to allow House to so confidently exclude the diagnosis like this. HOUSE: Of course! We're both right. Excellent solution. Everybody's happy. C'mon, step up, Foreman. If you think I'm right, order me to stick a needle in her brain. If you think Cameron's right, send the patient home. Either she'll be fine or she'll die. This didn't make sense. Sending a Munchausen's patient home meant she'd be fine? The ending to the episode indicated otherwise. FOREMAN: Do the venous sampling. Get her consent. [Cameron exits.] HOUSE: Nice move, boss. Way to cover your ass. FOREMAN: I just agreed with you. HOUSE: Not because you think I'm right. You're just taking the safe route. You're a wuss. Don't worry, your secret's safe with me. [Enters hallway.] Hey Wilson! Guess what Foreman just did. Nice touch, Foreman actually looking to see what the Magic Eight Ball said. Overall, the medical story was scattershot, like almost all of them were going off half-cocked. The Diagnostics office must have smelled like urine from everyone except Chase pissing on the furniture to establish territory. When House has been in charge, he has at least entertained other theories and has been willing to run through more than one of them. Here, it seemed like a contest to see who could make the right guess first, and anyone who entertained another theory was nothing more than a wuss who was playing it safe. In the past, the philosophical arguments between House and Foreman over playing it safe have not been about whether or not to test for more than one possible diagnosis, which House has been entirely willing to do and Foreman has never previously objected to. The "safety" argument has been over whether or not to practice experimental, aggressive *treatment* in the absence of a confirmed diagnosis, especially when all or part of that treatment is counter to standard medical ethics. So why all of a sudden was House acting like testing for more than one diagnosis was wussy instead of his own standard operating procedure? Why didn't Foreman (or Cameron or Chase) point out to House that he's acted on contingency theories himself in the past? This idea that you got only one guess, after which you had to treat and discharge or else be called a wussy doctor, was counter to the entire practice of differential diagnostics, and was a painful failure of the writing in "Deception." Whoever's writing the series these days seems to have watched "Damned If You Do" and "DNR," picked up on some vague notion of the "safe" vs. "risky" antagonism between House and Foreman, and yet managed to miss the actual substance of what the characters were arguing over. In "DNR," House didn't suggest a single one of the diagnoses he ended up testing or treating for. Not one. He took Chase and Cameron's differential diagnoses and pursued aggressive, experimental, and unethical treatments for them, and THAT was what he and Foreman (and Hamilton) clashed over. Arguably, they would have realized the original diagnosis was wrong even if House had done nothing, since the patient's paralysis was altered, not through anything that House did, but through the unforeseen effects of the steroids that Foreman had prescribed for the pneumonia. The thing that was admirable about House in that episode wasn't his aggressive medicine (which was a poor first resort considering he didn't even bother talking to the patient) nor even his diagnostic brilliance (which was given a rest in that episode), but his unwillingness to give in to a terminal diagnosis without double-checking everything first, which the punch-the-clock Hamilton wasn't willing to do. Anyway, even if the scientific aspects of the medicine in "Deception" were entirely accurate (and some things definitely felt questionable), the *practice* of medicine felt really wrong and out of character from the standpoint of intellectual methodology. All four members of the Diagnostics Dept. should have been saying, "Whoa, patient care first, winning the office betting pool on the diagnosis second." And while I could more easily forgive Foreman for not realizing it, it was stranger to me that Cuddy seemed unable to grasp (and then share with Foreman) the fact that leadership and technical brilliance aren't necessarily to be found within the same individual. There's no shame in telling House that you're going to follow up on his diagnostic hunches because his diagnostic judgment is better than yours, because it still doesn't mean that House has the temperament to run the department well. All Foreman really needed House there for was to pick his brains, not for House to call the shots. Should Spock have been in charge of the _Enterprise_ because he was more intelligent than Kirk? (Sorry, it was the only example I could think of that everyone would instantly get.) You'd think that both House and Cuddy would want Foreman to come away from the experience having learned something, but both House and Cuddy acted like there was nothing more to the job than whoever made the most right guesses. It was not only a childish view of what management is supposed to be about (7th-grade nerds insisting that whoever plays first board automatically gets to be president of the chess club), but it didn't even sound like Cuddy. FOREMAN: You chose me to make House miserable, didn't you? CUDDY: Apparently he's making you miserable. That's impressive. What on earth did Cuddy expect? It wasn't as if she didn't already know what it was like to try to police House, and that was when she had the proper authority to do so, not temporary, unenforceable authority like she gave Foreman. FOREMAN: Find someone else. CUDDY: No. For the first time in six years, I'm getting copied on all experimental tests and procedures. Clinic hours have been logged and completed. That last part didn't jibe with past episodes. House has been obsessive about telling the clinic nurses when he's logging in and out, and while he sometimes isn't seeing patients while he's doing clinic hours, we've seen no indication that he (or a surrogate) is not spending the hours there. CUDDY: You've given me four months of House's dictations so I can finally bill insurance companies. Finally, we find out at least one of the reasons why House's department is a "financial black hole." If the lagging or nonexistent insurance payments really represent that much revenue, the hospital might be better off if Cuddy got the Diagnostics Dept. a medical secretary to speed things up (but have the secretary report to Cuddy, not to House). At the point where Anica took the pills that Cameron left out as bait, I started to suspect that the answer was going to be that everyone was at least partly right. House had to be right, because it's his show. Cameron at least seemed to be right, since normal people don't take pills marked "dangerous, might cause seizures" for no reason. Since I knew the episode title going in (maybe I need to start avoiding even those from now on), I thought back to how Anica might be staging a deception without having Munchausen's. I remembered House pointing out that since she moved to the area without having a job, she must be leaving somewhere else. Then I thought, "Are hospitals somehow her way of hiding when someone else gets too close?" Was she running from a mobster ex-boyfriend who wouldn't let go, for example? But none of that came to pass. ACT III On Anica's chart: Javanovich, Anica ID: 85873 295-13-7865 ADM: 12-12-05 DOB: 04-09-66 The prologue took place on Dec. 12, 2005 In hindsight, the point at which House accepted that Anica had Munchausen's was the point at which I would have expected his usual associative diagnostic brilliance to kick in. The cause of the Cushing's was artificial, but the effects were manifestly real. He later informed us that the Cushing's suppressed her immune system, which should have informed his own reading of her earlier charts with the low hematocrit results. "I'm not a doctor, but" if you have reason to expect the entire blood panel to read low (aplastic anemia), and yet the white count is in the normal range, wouldn't that suggest a clue that the induced Cushing's could be suppressing a high white count, indicating that the Cushing's could be masking an infection instead? That was, in fact, a lot like how House ended up explaining it, so given his genius, shouldn't he have at least been suspicious of the truth all the way back when he was going through Anica's old charts instead of just assuming that since the cause of the Cushing's wasn't physically significant, the effects of the Cushing's weren't significant either? I have no idea whether Cushing's syndrome actually behaves like this in real life, but from the standpoint of the internal consistency of the story, this was really fishy to me. HOUSE: Look, I checked the records. All her hospitalizations were for different things: brain tumor, fainting spells, skin rashes, seizures. She's had every blood test known to man and the results were all over the map. There's only one constant: low HCT. The anemia's real. CAMERON: There's a million things she could have taken to have done that. HOUSE: True. It could just be her M.O. She self-induces two illnesses. One always changes, one never does. Except that this was the second time (that we know of) that Anica induced Cushing's. Since Cameron was the one who first went back over Anica's previous hospitalizations looking for a pattern, why didn't she catch this? If the point of Foreman's approach was to prove House wrong, then why didn't Foreman catch that House's initial dismissal of the anemia was a bad guess? If the point of Cuddy's admiration was that House is all that, then why didn't House go through the records to begin with (he who *used* to insist on getting an exhaustive medical history) and catch this instead of dismissing the anemia? The characters felt contrived to always be looking the other way just so that in the final reel, House could spring the Colonel-Mustard-in-the-conservatory-with-the- candlestick ending. HOUSE: You may not have Salma's ass, but she doesn't have your eyes. I had a lot of trouble believing a PPTH lab tech would fall for a line like that, especially given House's reputation and the fact that House's underlings are usually crowding the lab themselves with no respect for turf because House doesn't trust other people to do lab tests. If I had to deal with cancer patients, I don't think I would have an edgy poster for an edgy Hitchcock movie in my office, but what the hey. :) CHASE: No way. I just got back from a suspension. HOUSE: And if it wasn't for me, you would have been fired. True in the larger sense, but all House really did was get Chase to save himself from himself. Chase should have told his once and future boss that he now needed the same thing. HOUSE: Right now, Blackpoleon Blackaparte has got the nurses on red alert. It's not even offensive anymore. It's just boring. How could they do that to House: put boring lines in his mouth? CHASE: I also realize that no matter what I do, you're still gonna treat me like crap. HOUSE: 'Crap' is a relative term. Loved Spencer's economy of crestfallenness. FOREMAN: Nurses called the attending as soon as a trocar was ordered. So Foreman did have the practicing privileges of an attending? That sounded way off base. Or did he mean that Cuddy was notified and Foreman was her proxy? CUDDY: I just processed your patient's discharge papers. She's on her way out right now. With a diagnosis of Munchausen's, wouldn't discharging (even after a quick psych consult, which didn't seem to happen) be out of the question? Wouldn't the patient being a danger to herself (submitting herself to unnecessary surgeries and inducing seizures) be enough to warrant at least a temporary involuntary admission before they had to let her go? HOUSE: Sit. ANICA: Why? HOUSE: So you don't crack your skull when you pass out. So House warns only those patients he thinks are hot, not obnoxious cheating bicyclists? HOUSE: Colchicine decimates your white blood cells, leaves almost no trace. It's great for faking your way into hospitals. Just so Anica didn't miss its future applications, nor how to ask her friendly online pharmacist for it by name. HOUSE: I'm going to give you a cocktail of insulin for seizure and colchicine to kill your white count. This will absolutely confirm my diagnosis of aplastic anemia. There is one small catch. If you've actually done something to yourself to cause the anemia, then I'm wrong. And if I do what I plan to do, then the treatment will kill you instead of saving you. So I need to know. Have you been taking anything besides the insulin, the ACTH, and the pills Cameron left in your room. ANICA: No. HOUSE: Good. Gimme your arm. What, "Everybody lies" except Munchausen's patients?!? House was taking a huge risk that Anica would trust him not to be running some kind of scam on her the way Cameron did, and that she wasn't lying about other self-medications and simply counting on being resuscitated because she was so close to a hospital. And shouldn't House have found a more hidden place to inject Anica with the insulin/colchicine? If the other doctors found the fresh needle puncture, wouldn't they have suspected Anica of self-injecting again? Or House of injecting her? ACT IV FOREMAN: Once she's stable, we need to get her out of here before she does more damage to herself. Why not involuntary psych admission then? They already knew Anica had a pattern of moving from hospital to hospital. Why was turfing her being treated as the safe option? House has certainly been willing to argue in court in the past that someone was mentally incompetent even when they weren't. ANICA: Who are you? FOREMAN: I'm Doctor Foreman. I'm in charge of your case. I wasn't sure what kind of message they were trying to send with Foreman pulling a House and not meeting the patient until the very end. That he was more like House than he realized? That he didn't have an appreciation for how the time spent on the administrative aspects of the job got deducted from the time spent with patients (not that House ever spent much time on administrative matters)? FOREMAN: I know this is scary, but a bone marrow transplant could cure you. FOREMAN: We'll uh, we'll check the registry, see if there's a donor match. You don't need to get a sample of bone marrow in order to match it against the transplant registry? (Just asking.) WILSON: We have to kill all the old bone marrow before we give you the new stuff. You'll have no immune system. I really didn't get this. All the previous objections to House doing a bone marrow biopsy had been removed. Foreman finally thought House was right. Why didn't House, Foreman, or Wilson then go ahead with the biopsy without jumping straight to irreversible bone-marrow destruction? Given that we were supposed to be looking down on Foreman as the overly safe doctor here, why didn't he do a simple confirmation of the diagnosis? And then there was House, who had been *pleading* for a biopsy before, but once he had the phony symptoms to show off, was perfectly content to treat those as just as good as real symptoms. That wasn't just "risky medicine"; it was a snake oil medicine show. There was no science in it at all. Yes, I understand that he did it in order to keep Anica from being turfed with suspicious symptoms and a "Do Not Take Seriously" sign on her forehead, but once he had her readmitted via his ruse, he should have persisted in his quest for the *genuine* confirmation of the bone-marrow biopsy. And it's not like Wilson is Dr. Live-on-the-Edge. At least one, and preferably all three of those doctors should have put on the brakes before House literally sniffed out the final diagnosis (and it wouldn't have come amiss for Cameron, Chase, or even Cuddy, who was being copied in on everything, to question this either). That felt contrived by idiot plotting just to allow a problematic but not yet fatal condition to all of a sudden be made a matter of life and death so that House could swoop in and save the day. In "DNR," House didn't even claim to know what was wrong with Giles, nor even that Hamilton's diagnosis was wrong. It wasn't about who was the best diagnostician. It was about House being a fanatical epistemologist; i.e., about questioning and going over the possibilities again in a methodical manner to make sure of the diagnosis, and Foreman took issue with House using unwanted and unethical heroic measures in order to go down his checklist. While I agree with House in the abstract that "error rates" need to be double-checked, if everyone's going to argue based solely on results (like Cuddy's, "[House] gets lucky a lot"), then it's worth noting that if House had done nothing and just waited for Foreman's steroids to kick in, he would have gotten the same diagnostic clue without all the harmful and unethical acts. I cannot believe that in the space of a single year, House would go from being obsessive enough about double-checking a diagnosis to risk prison and his career, to just popping diagnoses out and then not wanting to hear alternatives nor even do conclusive testing once he gets his way. This is a marionette version of House, where the writers jerk on the strings and the puppet apes the outward motions of past behavior, but the underlying substance isn't there. It's also a marionette version of Foreman, who pushes for the rules and for safety except where it suits the writers' plot devices. It's a marionette version of Cuddy, who has successfully interceded in House's guesswork before ("Damned If You Do"), even if the result was only to get House off of an unproductive path and prod him into exploring alternatives. The idea that luck and unconfirmed guesses are enough to qualify House for unchecked latitude didn't used to be enough for her. And since when did Wilson become that reckless? HOUSE: She doesn't have aplastic anemia. She has an infection. CAMERON: No. Her white count would be through the roof. Hers is on the floor. CHASE: She had no fever. HOUSE: 'Cause her self-inflicted Cushing's suppressed her immune system. It stopped her from having a fever and hid the infection. _Clostridium perfringens_ could cause the bruises, the schistocytes, the anemia -- CHASE: Explains everything except the white count. HOUSE: She would have gotten sicker when I said she was gonna get sicker except Cameron dosed her with the antibiotics. HOUSE: [To Anica] You have a bacterium. It's on all of us, but the bruises you gave yourself with the Cushing's made a lovely home. Just how long do the effects of injected ACTH last? Anica showed up at the PPTH emergency room on the 12th and no one was alarmed by her white count then. House said she should have gotten sicker by the next day, except that Cameron tricked her into taking antibiotics, which presumably kept the white count from rising due to the infection. The bacteria took over that fast and then quieted down that fast from the rifampin? Since House confessed to an unethical treatment and Foreman was in charge, shouldn't that mean more official disciplinary action against House? Or was Foreman not even going to bother trying because Cuddy wouldn't back him up? FOREMAN: If you were serious about the offer, I'm serious about accepting. I'd like to run the department. And you said it yourself. Things run smooth. CUDDY: Except for the part where House went behind your back and KO'd the patient with insulin and colchicine. FOREMAN: There was no reason to suspect an infection. Even House didn't think it was an infection. You would have done the same thing I did. CUDDY: And I'd be just as wrong. This was inexplicable as a reason to prefer House in charge rather than Foreman. Foreman was right. If Cuddy was going to go strictly by results, the ends justifying the means and nothing else, then she was getting the best of both worlds from the current setup. The hospital was still getting the benefit of House's brilliance but more paperwork and billing were getting done under Foreman. There was no essential difference between House going behind Foreman's back in this episode and House going behind Cuddy's back in other episodes, so why did Cuddy cut Foreman off at the knees for something she tolerates in herself on a routine basis? In fact, Foreman functioned in "Deception" in much the same way that Cuddy did in "Damned If You Do." No, Foreman didn't reach the right final diagnosis himself, but he and Cameron were instrumental in forcing House to let go of a bad earlier diagnosis that he was enamored of to the patient's detriment, and move on to new avenues. The idea that Cuddy was so dazzled by House's ability to accidentally stumble into a correct final diagnosis in "Deception" that she therefore wanted to see him as the alpha male again, just made her come off as House's biggest fangirl apologist. CUDDY: What House did was insane, but he saved her life. FOREMAN: He got lucky. CUDDY: He got her to admit she's got a problem. She's agreed to outpatient treatment. Except that they showed us that Anica was off scamming the system again at the end with an assist from House. So what did that say about Cuddy's appreciation of House's results? CUDDY: He gets lucky a lot. That he does. Occasionally, House's luck should run out (and I don't just mean the ponies), since even when you make percentage guesses, you're not going to be right 100% of the time. I'm even willing to buy his earlier claim that when he doesn't take risks, more patients die than when he does take risks. But we should be allowed to see that once-in-a-while patient on whom House gambles and loses. It's only fair that after we see House save nine out of ten patients by experimental treatments, we should also hear House try to explain that the experimental treatment that's killing the tenth patient would have paid off in the other nine cases, and this patient just ran out of luck. Somehow I don't think the patient would be sympathetic to House's explanation. In this specific case, this was the first time we've seen House reclining in a patient's bed. Since he was trying to get at Anica's racing picks, not gather more diagnostic information, it wasn't his genius that led him to her room. If Anica's case had gotten up on the whiteboard via any other means than sharing a love of the ponies and the same betting shop with House, then House would have gone ahead and put her through the unnecessary and dangerous destruction of her bone marrow. This episode's path to the correct final diagnosis was not what scientists would call a "reproducible result." That Cuddy felt reassured by House's abilities this week was frankly unbelievable and it was revolting that the writers seemed to want us to share Cuddy's reassurance and gross stupidity. Cameron getting angry at a suspected psych patient just seemed like more of the same. She didn't *know* it was Munchausen's any more than House *knew* it was Cushing's, but what she's really learned from House is his arrogance. If it was Munchausen's, all she needed to do to provoke a reaction was clinically tell Anica her deception had been discovered and that as soon as Cameron could convince her colleagues, she was going to expose Anica. The malice was unnecessary. If we were meant to see it as deliberate characterization, then Cameron came off the worse for it. If we were meant to see it as diagnostic, then the writers came off the worse for it. Plus, we found out that the antibiotics did some harm in that they suppressed the symptoms of the infection without actually treating it, thus delaying diagnosis until House got lucky. I know there are safer ways to discolor urine. There were a lot of lucky doctors this week. FOREMAN: She should have died. House is not a hero. A person who has the guts to break a bad rule, they're a hero. House doesn't break rules. He ignores them. He's not Rosa Parks. He's an anarchist. All he stands for is the right for everyone to grab whatever they want, whenever they want. You tell doctors that's O.K., your mortality rate is gonna go through the roof. The Rosa Parks contrast was true enough. House wasn't engaging in civil disobedience to protest a bad rule or law and get it changed. But Foreman is bright enough to know that the anarchism charge isn't true. He's known for a while now that House doesn't want his subordinates or other doctors that he sees as inferior doing whatever they want whenever they want. House wants everyone to do what House wants, or else have the guts to make their own stands for what they think is right. As near as I can tell, he's flying by Plato's _Republic_, the rule by philosopher-kings, but it's the Classics Illustrated version for twelve- year-olds, where they don't bother telling you that a lot of boring responsibility comes with the entitlement to rule from on high. Foreman's anarchism complaint could have been better argued. House isn't in favor of no rules, just in favor of the rules not applying to him. But in the larger sense, Foreman was right about the point of having rules not being to hamper House, but to keep from sending the message that everyone can use their own judgment when it comes to breaking rules. (But if Foreman was going to complain about first House's, then Cuddy's utilitarian approach to ethics, then how did he justify sending House and Cameron to break and enter Anica's home, and why didn't one of the other doctors point that out?) I'm reminded of my favorite episode of _Hill Street Blues_ ("Trial by Fury," third-season debut). The cops catch some suspects in a rape- murder case, but the only evidence they can hold them on is for lesser charges. Capt. Furillo conspires with the D.A. to release them on their own recognizance rather than hold them on the lesser charges, because they know there's a community lynch mob waiting for the suspects. Rather than face the mob, one of the suspects rolls over on the other. Furillo's pleased with himself and the other cops think he's a hero. His girlfriend chews him out, though, saying that maybe Furillo's judgment really is that good, but sending the message to all the other cops that it's O.K. to bend or even break the law to suit their own judgment is just plain scary. Even when House's judgment is at the top of its form, you really don't want every doctor deciding that his or her judgment is all that it takes to justify breaking a rule. (And in this episode, House's judgment was not at the top of its form.) Foreman was right to point out to Cuddy that the mortality rate would go through the roof if that happened. On top of everything else, if Cuddy had no intention of giving Foreman the job permanently, then it was really scuzzy to offer it to him and then back out. Great ethical leadership skills there. Now Foreman knows that his subordinate (House) will do anything behind his back that he feels like doing without fear of disciplinary action, and his supervisor (Cuddy) will lie to him and refuse to back him up, giving him all the responsibility of the position with none of the actual power. This is ridiculous on so many levels for Cuddy (and the writers) to be so smug about. Foreman wore nice suits throughout the episode and no lab coat, like he was consciously rejecting House's homeless chic as a proper look for a doctor, but had subconsciously picked up from House that the one who doesn't wear the white coat is the one in charge. HOUSE: Kinda digging this whole Foreman-in-charge thing. [Grabs candy.] You know. [Indicates cashier.] Frees me up to watch my soaps, catch a movie in the afternoon, have lunch with you. WILSON: Yeah, that's a big change for you. [Pays cashier.] HOUSE: Now, Cuddy's up Foreman's ass, not mine. [Takes change.] WILSON: You couldn't live with Foreman as your boss. HOUSE: Why not? People can change, you know. Wilson said otherwise. Why would House lie about this particular thing to Wilson, of all people? Why Wilson doesn't make House pay his own way baffles me. "People can change" is reminiscent of what House said to Stacy. And no one really did change in this episode (unless you count simply breaking with past characterization). I'm not sure what House's motive was in saying it, unless it was to keep from giving anyone the satisfaction of seeing him chafe under Foreman, because the writers have decided that now House does care what other people think after all. But the fact that Anica went back to embracing her Munchausen's, armed with new and improved ways to fake illness taught to her by House, and how not to get caught, taught to her by Cameron, made this final diagnosis hollow. Meanwhile, at St. Sebastian's: DOCTOR: Your white count is way down. ANICA: Oh. DOCTOR: We're gonna need to admit you. Just run a few more tests. ANICA: Whatever you think is best. Anica promising to get psych treatment only to move on to deceive her next hospital reminded me of one of my biggest worries about "Control." House doing nothing more than telling someone with psych symptoms to go forth and do better next time seemed radically insufficient for the task. Here they explicitly made that case. It looked like there were five or so unredeemed betting slips where House threw down Anica's racing form. Evidently her luck didn't hold. Isn't there a new _Racing Form_ every day? If so, then wouldn't Anica's picks from the 12th or the 13th be out of date by the time House got around to betting on them? (I checked, and it was the exact same marked-up page that she hid from him behind her pillow during the initial medical history scene.) Or was he just taking her word for it that the horses she picked for the previous races were good ones to bet on in future races? Since they had House take a Vicodin when he made his final bet, maybe they were trying to play up the addiction angle after all. Or maybe it was just disappointment when Anica didn't show, because that meant that he realized she had probably taken her business elsewhere, in more ways than one. Counting up the deceptions, there were Anica's Munchausen's, House's pretense at botching the lumbar puncture, Cameron's mislabeled antibiotics trap, House's phonied-up blood tests, House's insulin/ colchicine injection, Anica's lie about getting psych treatment, and probably Cuddy's permanent job offer to Foreman as well. Based on the wardrobe changes and Anica's chart, the action took place on four or five distinct days starting on 12/12/05. The prologue may have been on a separate day, but it was hard to tell. The days were probably continuous, except for the last day, which seemed to take place after Anica had had time to benefit from her course of antibiotics (but the Christmas decorations were still up at the OTB). Vicodin count: 2 Medical synopsis: grand mal seizure, bruises on torso, anemia, blood alcohol level of .13, afebrile differential diagnoses: STD, infection, alcoholism w/ DIC (disseminated intravascular coagulation), SLE (systemic lupus erythematosus), familial telangiectasis, Cushing's syndrome MRI (negative), abortive lumbar punctures hypertensive crisis IV Lopressor drip differential diagnoses: ACTH(adrenocorticotropic hormone)-secreting tumor on the lung or pancreas, alcohol detoxification pan-man scan mass on her pancreas emotionally undisturbed upon hearing potentially terminal diagnosis biopsy of mass (negative) elevated ACTH level differential diagnoses: brain tumor, Munchausen's syndrome two appointments with two doctors reading glasses w/ multiple prescriptions diagnosis: tumor pressing on the optic nerve self-administered mislabeled rifampin (antibiotic) low HCT (hematocrit) diagnosis: Munchausen's syndrome and aplastic anemia injection of insulin and colchicine induced seizure, induced low blood panel symptoms three minutes of radiation schistocytes (they slipped that one in at the last minute) "grapey" odor final diagnosis: Munchausen's syndrome and _Clostridium perfringens_ (bacterial infection) whose symptoms were suppressed by self-induced Cushing's syndrome Augmentin presumed self-injection of colchicine to gain new hospital admittance Clinic patient: vaginosis from self-administered bacterial culture medium and chronic stupidity antibiotics and sexual abstinence And, because it's a Christmas episode, The Ghosts of Medical Aspects Past: Explaining away all the symptoms as alcohol abuse ("The Socratic Method," although this time it was Foreman rather than Chase). Diagnosis of DIC ("Humpty Dumpty," although this time alcohol-induced). Diagnosis of lupus ("Detox," although they named a specific type this time). Cushing's syndrome ("Heavy," although here self-induced). House calls his boss into the clinic for an unnecessary consult just because he's chafing at being told what to do ("Occam's Razor," although it was Foreman this time instead of Cuddy). Patient is emotionally undisturbed upon hearing potentially terminal diagnosis ("Autopsy," although 'terminal' is a relative term). Reddish tears from rifampin ("Kids"). Diagnosis A causes doctors to stop considering any further diagnoses ("Three Stories," although here it was Munchausen's rather than drug addiction). Injections w/ insulin to induce seizure ("Histories," although here joined in by House). Colchicine fools doctors by mimicking symptoms of other illnesses ("Occam's Razor," although this time it was deliberate). Bone marrow transplant proposed, then dropped ("Daddy's Boy," although this time they explained why). Schistocytes ("Kids").