House: Putting your job on the line on an effort to stamp out stupidity isn't [stupid]?

Cuddy: You would.

House: Probably. But then I also would try to cure cancer by infecting a guy with malaria to win a $50 bet. You really want to be like me?

— 5 to 9

5 to 9 is a 6th season episode of House which first aired on February 8, 2010. The episode follows a day in the life of Princeton Plainsboro's Dean of Medicine, Dr. Lisa Cuddy, and the inner workings of the hospital are seen through her eyes. This day proves to be especially trying as Cuddy wrestles with myriad hospital issues and staff disputes that test her perseverance and skills as an administrator, all while juggling issues in her personal life.

Once again this season, the series takes a big step away from the "case of the week" format, this time to focus on Lisa Cuddy. House was designed as a character driven drama, but one consistent and valid criticism was that although House himself was well developed and interesting, the rest of the characters tended to be stereotypes without a background. Although there had been hints at Cuddy's backstory before this episode (and she would be much better developed in Season 7 ), this is the first episode we get a full insight into her daily struggles.

By focusing entirely on Cuddy in this episode, viewers finally were able to see another fully formed character with her own motivations, fears, talents and personal life. Far from being a typical day for Cuddy, she has to deal with a number of problems while risking her job by playing "chicken" with the hospital's #1 insurance company. Many of the scenes with House are particularly poignant as she seeks reassurance from a man who puts his job on the line "24 times a year". House, for the most part, offers only annoyance (which is echoed by several of the doctors he works with) but in the end he reminds her that while she may be worried about her job, she's also more worried about the hospital. This parallels but does not mirror House's dedication to his puzzles and his patients over his own job security. House also admits that she's literally the only person who can keep the place going.

The episode also helps us understand the daily interaction between Cuddy and House. Prior to this, we only got glimpses into Cuddy's day, seen solely through the eyes of House and his fellows. As the writers of the episode fill in the blanks that usually exist in the audience's view, we realize that House is often the least of her worries.

But another point is raised that we see in another episode, where Wilson points out that most people in Cuddy's position have a senior staff to deal with the issues she deals with herself. Nevertheless, Cuddy manages to stay focused on all the balls she's juggling - putting one aside just long enough to pick up another. Despite her busy day at the hospital, she doesn't forget she has a sick daughter at home either. She gets frustrated and angry, but her anger is directed and productive, and usually fully deserved. She doesn't take her bad day out on anyone, instead seeking refuge so she can think things through.

Lisa Cuddy's alarm goes off at 5:00 a.m. She does a bit of yoga, then hears Rachel crying. She realizes she has a fever and comforts her before having a shower. She gets ready for work as the nanny arrives. Just as she's about to leave, Lucas drops by and talks her into a quickie. House sends her an emergency page, but she tells Lucas to ignore it. Lucas lasts all of two minutes and Cuddy goes to leave at 7:46.

Cuddy arrives at the lobby at about 8:10 AM, only to have Nurse Regina tell her there's a problem at the pharmacy. House catches up to her too, but she blows him off. House follows her to her office where he tells her that he accompanied Lucas on stakeout to determine if the subject had a soft tissue injury. He says he paged her to interrupt her because Lucas claimed they always had sex in the morning. Cuddy denies it. Nurse Regina comes in with more emergencies, but Cuddy just asks her to proofread her proposal because her assistant isn't available.

Cuddy runs into Claudia, the call center supervisor, and tells her she's hired extra staff and to make sure the telephone network is working properly. She won't tell Claudia what's going on, .

Cuddy goes to the pharmacy and Oscar tells her their supplier has sent them a double order. She tells him to fax them the purchase order, but he hasn't been able to find it. He asks him where the head pharmacist Stan is, but he's not in yet. She tells him to let Gail to deal with the mistake when she gets back. As she's about to leave, she then asks if it was just one order and if it was Vicodin. Oscar confirms it was just one drug - ephedrine. Cuddy tells him to have Gail see her as soon as possible. Nurse Regina comes in to tell Cuddy her 8:30 appointment is there, but Cuddy is paged and tells the nurse to get the visitor coffee.

Cuddy goes to deal with the emergency page and finds Dr. Hourani in the operating room complaining it's too cold. She asks why he doesn't just hurry and he tells her House bribed the physical plant superintendent to turn on the air conditioning to make him hurry up. Meanwhile the patient's body temperature is dropping. Cuddy promises to take care of it and calls the superintendent. She runs into House who tells her his patient with the mystery infection is covered in boils and has a large abscess. She promises him the operating room will be available soon.

Cuddy gets a call from the nanny - Rachel is vomiting and has a fever. She tells the nanny to give her ibuprofen and to call her in half-an-hour. She finally arrives for her meeting with Eli Morgan, the insurance company representative from Atlantic Net. She tells him that if they don't sign a new contract on her terms by 3 PM, she's ending their contract. He thinks she's bluffing and leaves.

Cuddy gives Nurse Regina a script to take to the call center and tells her to make sure each copy is accounted for. House intercepts her leaving her office and tells her that she should have worn a sexier bra to close the deal. He realizes that either the insurance company or Cuddy made an unreasonable ultimatum, and she confirms it was her and isn't bluffing. House's patient has congestive heart failure, but Cuddy still refuses to go with his treatment plan - deliberately infecting him with malaria.

Dr. Thomas, the Chief Surgeon, intercepts Cuddy on the way to her meeting and complains about House's stunt and that she still hasn't hired him a replacement for Chase. He accuses her of spending too much time dealing with House and says he only took Chase on as a favor to her. She asks why, if he didn't want Chase in the first place, why he's worried about losing him. Thomas threatens to quit if she doesn't do her job.

Cuddy goes to a meeting with the Board of Directors. She tells them she made a final offer to the insurers. Dr. Simpson thinks she's crazy - Atlantic Net covers 80% of their patients. However, she convinces most of the board that the insurance company can't afford to cut them off without alienating their customer base. However, Chairman Sanford Wells tells her that if she can't get the contract, her contract will come to an end.

House hasn't shown up for clinic duty, so Cuddy fills in. She deals with a patient who wants a prescription for breast milk to treat his colon cancer. He thinks the insurance company will have to pay for it if he has a prescription, but Cuddy tells him that it isn't the case. She tells him she can't help him.

Cuddy finds out that one of the doctors on the emergency room on-calls list doesn't have hospital privileges. He's supposed to be a replacement for the regular on-call doctor. Cuddy tells the nurse to call Dr. Ereshevski to fill in.

Cuddy finds a lawyer in her office representing a patient suing for malpractice. She goes to speak to Chase who sewed the patient's thumb back on rather than just covering up the exposed bone. The patient is suing to avoid paying the full bill.

Gail has arrived and it's obvious to Cuddy that she double ordered the ephedrine as a diet pill. She tells Gail that although she won't report her to the DEA, she has to fire her for stealing drugs.

Cuddy takes time for lunch in the cafeteria and runs into Wilson. She can't reach her nanny. She asks Wilson's advice on what to do with the insurance company, but he has no answers. He suggests she ask House.

House is waiting in her office. His patient has renal cell carcinoma and he still wants permission to infect him with malaria. Cuddy realizes House has a bet going on whether he can use malaria to diagnose the patient. House tells her she's making a bigger bet with the insurance company.

Cuddy runs into Stan and tells him to complete an audit on the ephedrine orders even though Gail has confessed. Lucas drops by with food, but Cuddy is mad at him for discussing their sex life with House. She asks why the nanny isn't calling her back, and Lucas tells her that he told her not to bother and that he would report Rachel no longer has a fever, although she has a small rash. Cuddy immediately calls the nanny, but the phone rings in Lucas's pocket because he grabbed it by mistake. He's also turned off the ringer at home because he was sleeping. He suggests they deal with the insurance company by investigate them. Cuddy thinks there is no time, but is intrigued as to how Lucas works.

Lucas tells Cuddy where the insurance company CEO is having lunch. She tells him how little her plan will cost, but he's unmoved.

Cuddy arrives back and finds Stan looking for her. He's found that Gail has ordered an extra ten cases of ephedrine by altering the paperwork after he signed it. She got away with it because she also had responsibility for double checking the invoices. She figures Gail was supplying a methamphetamine lab and tells Stan to call the DEA and get Gail back in to the hospital.

Eli is waiting in Cuddy's office with a new proposal. However, he's only offering two-thirds of what Cuddy wanted and she turns him down. He says she either has to take it or leave it because she won't get what she wants. Cuddy goes to the stairwell to think, only to find House waiting for her by the door when she leaves. Now his patient has liver failure, but he swears he didn't infect him with malaria. She asks him what he would do about the insurance company. He tells her to focus on the numbers rather than trying to make a point that might cost her her job. She says he risks his job all the time, and he asks if she really wants to be the type who tries to infect a patient to win a $50 bet.

3 PM rolls around and Cuddy calls a conference for staff to announce that they are cutting off the insurance company contract at 5 PM that day. She's doubled the staff in the call center and plans on announcing that existing patients will be allowed to stay for 30 days. However, they will no longer accept new patients with Atlantic Net insurance.

Foreman comes in to see Cuddy, who is still trying to reach the nanny. Foreman announces that House wants Chase to do the patient's liver transplant instead of Dr. Hourani just to show Dr. Thomas that Chase was his best surgeon. However, in order to allow this, they need Cuddy to schedule the operating room. Cuddy goes to see House, who is with a masseuse. She tells him to get his department under control. He tells her that the insurance company isn't just going to give in to her public relations campaign.

Cuddy calls in Mr. Acevedo and his lawyer. She tells them the hospital hasn't been paid because of the suit. The lawyer wants $50, 000 for pain and suffering, but she offers to settle if they pay half the deductible for the surgery - $16, 000. The patient tells her that if they hadn't reattached his thumb, he would actually be in better shape financially because he hasn't been able to work because of the recession anyway. Suddenly Dr. Cuddy gets a page. The lawyer says he will see them in court, but Cuddy says that they intend to get paid and if they have to take Mr. Acevedo's house to do it, they will.

Cuddy finds Dr. Thomas and Dr. Chase having a fight. She breaks it up and goes to see Gail in her office. Gail admits to the deception, but threatens to say that House convinced her to be the ephedrine supplier and that Cuddy overlooked it because she and House were having an affair.

Nurse Regina tells Cuddy that Chairman Wells wants to speak to her. When the nurse says he won't wait, Cuddy tells the nurse to tell him she has quit. Cuddy goes to sit in her car, but House finds her there. She tells him to pay Lucas the bet he made - they were having sex when he sent the emergency page. House tells her the breast milk guy found a doctor to give him a prescription. Cuddy admits that she thought the insurance company would back down. House tells her the board won't fire her because the hospital needs her. He also tells Cuddy he knew Gail was a sociopath by watching her open mail. He didn't tell Cuddy because he didn't know about the pharmacy theft and thought it could be leveraged at a later date.

Using the knowledge House gave her Cuddy goes back to speak to Gail. She tells her if she tells the truth, she can help her. Gail tells her she's an idiot and that she started stealing six months after she was hired, that Cuddy hasn't found the full extent of the theft, and that if she goes down, they go down together. However, Cuddy has surreptitiously recorded the conversation on a recorder disguised as a flower that Lucas gave her and plans to give it to the DEA. Cuddy then heads off to the board to resign.

Cuddy finally get in touch with the nanny, and Rachel is fine. She misses an elevator and finds Eli coming to see her. The insurance company has caved in and agreed to her terms. Cuddy calls out in triumph. She goes to the board, who congratulates her with applause. She's given an ovation by the staff. She goes to her office to find an installment check from the Mr. Acevedo, but tears it up.

Cuddy goes home to see Rachel and Lucas.

• Cuddy not being able to keep assistants is a referential nod to another program about a working woman who has a problem keeping an assistant - Murphy Brown, portrayed by Candice Bergen.
• NASCAR is the largest and most prominent promoter and sanctioning authority for stock car auto racing. In the United States, it draws more television viewers than any other sport's body except the National Football League and 17 of the top 20 single day most attended sporting events in the world are NASCAR races.
• Jimmy Cliff is a Jamaican ska and reggae singer. The line "the bigger they are, the harder they fall" is from his hit The Harder They Come, written for a movie by the same name. The song has been covered by numerous other artists.
• More about Health Insurance in the United States. Unlike most industrialized countries, the United States does not have universal health care coverage. Insurance companies are permitted to insist their policy holders go to a certain limited number of hospitals and doctors in their "network". Agreements such as the one between Princeton-Plainsboro and Atlantic Net are common.
• Cuddy and Eli talk about a "capitation structure". This is an arrangement where the hospital would be assigned a group of patients and be paid a flat rate for their care whether or not they actually use services. This creates an incentive for the hospital to avoid expensive unnecessary procedures and to encourage them to use preventative care on patients. Cuddy is most likely afraid that the resources used by this group of patients would exceed the amount she was paid for them. Her request for an increase is to offset the hospital's risk in agreeing to this flat rate structure.
• The novel on Cuddy's nightstand is Inés of My Soul, by Isabel Allende, a fictionalized account of Inés Suárez, a woman who played an important role in the conquest and colonization of what is now Chile.
• Deliberately infecting a patient with malaria was a treatment for syphilis prior to the development of penicillin. Malaria causes a high fever which could kill off the syphilis bacteria. After the syphilis was gone, the patient could then be given quinine to treat the malaria. However, there is no apparent protocol for using it to treat drug resistant staphylococcus or cancer.
• The numbering of copies of a document is a common way of ensuring that any leak of the document can be traced to the person who possessed it. Cuddy is concerned that someone in the call center might contact the press to let them know what's going on, or someone may have had the opportunity to contact the insurance company, giving them a leg up on the negotiations.

• As Cuddy is working in her office just before 3 PM, although the clock on her desk shows a time near 3 PM, shots of her wrist watch show the time is about 1 PM.
• Cuddy's bra and panties are clearly showing in the shower scene.
• All hospitals and pharmacies routinely have two people check all orders and shipments of all controlled substances, specifically to prevent the sort of scheme Gail perpetrated.

Consent to treatment:

Chase may have the best motives in sewing a thumb back on, but in reality the lawsuit isn't out of line (although the claim for damages might be excessive). This is also the sort of incident that could risk a physician's license. Even House was charged with assault for resuscitating a patient against written instructions in DNR. The cost of medical treatment is a relevant consideration for a patient when providing consent. Certainly, had Chase merely "upsold" the procedure by performing a more expensive procedure with little extra benefit, he would deservedly receive condemnation. Perhaps the bottom line is that Chase should have sought out ethical assistance in the situation.

For similar issues, see the appropriately named episode Informed Consent.

Treatment in absence of insurance:

Among developed countries, the United States is perhaps unique in requiring physicians and patients to consider the cost of a medically necessary procedure. In most developed countries, sewing the thumb back on would be a medically necessary procedure covered under insurance. Here, the patient has a $400 option (suturing the open wound) or a $16, 000 option (sewing the thumb back on). High deductibles were generally the rule in the United States at this time. Even under the Affordable Care Act (aka "Obamacare") deductibles are still an issue, although they now tend to be lower.

For all the talk about "people can go to emergency rooms" (which is what happened here) and the fact emergency rooms are required to treat patients who show up there, the facts are that:

• The hospital can still charge full fare for any procedure they perform, even if they don't expect to be paid.
• The hospital only has the duty to stabilize the patient, not given them the appropriate treatment or ensure they can be sent to someone needing medical care.

Teaching hospitals often perform procedures for free as a way of training students, but this is widely seen as disregarding the patient's best interests, particularly their privacy interests. Having an operation under these terms was one of the reasons the father of Canadian single-payer insurance, Tommy Douglas, fought so hard for the end to a pay-for-play system.

Use of experimental procedures:

The FDA exists for a reason, one of which is to approve medical treatments and to keep statistics about their safety and efficacy. A physician who directs a course of treatment that is known to be useless faces both license sanctions and federal law violations.

In-between are procedures that may or may not be useful. In most cases, the FDA wants to fun full double-blind trials, but this is not always possible, particularly for uncommon conditions. In fact, many common medical procedures, from the humble tonsillectomy to a heart bypass never went through this requirement and are only now under review for their clinical effectiveness, particularly compared to less invasive and less dangerous procedures (antibiotics and lifestyle changes respectively).

House is correct he would need Cuddy's approval to deliberately infect his patient with malaria. This is by no means an approved treatment for anything. Although being one of many possible treatments for syphilis in the past (some of the others being sulfa drugs, mercury injections, and yes, malaria), if it were identified as syphilis, antibiotics would be the only reasonable course of treatment.

Now, it's not like House's reasoning is faulty (see Mirror Mirror, where he also has to induce a fever to keep a patient alive). The problem is that many proposed treatments seem like they should work, but for one reason or another, they do not. Another issue is the danger of the proposed treatment - malaria is a serious disease all by itself posing a real risk of inducing a chronic condition.

Naturally, House is putting his medical license on the line here. He's done this sort of thing on several previous occasions, such as in Whac-A-Mole where he used a test that "wasn't quite FDA approved".

Ironically, many of the legitimate procedures used in the series were completely FDA approved yet posed a far more serious danger to the patient. Hemispherectomy is an approved treatment for some brain disorders and melarsoprol kills about as many patients as it cures, but is the only possible treatment for African trypanosomiasis.

Writing useless prescriptions:

The general consensus is that physicians should not write prescriptions for treatments they know to be ineffective. However, this extreme is somewhat controversial as some physicians (most notably, Dr. Mehmet Oz) believe that if the treatment provides the patient with some comfort and alleviates their anxiety, it is justifiable. Other physicians, however, note that all of these "alternative treatments" cost money and the cost/benefit analysis alone requires the physician to deny the request.

Cuddy is completely in the right here. Breast milk won't do the patient any good and giving him the prescription won't require his insurance to pay for it. Given that the patient needs his insurance to cover it, it's also clear that this "treatment" is likely to be expensive. It's also possible that the "online" articles the patient has been reading were created by the very people who are trying to sell him the product. In addition, pharmaceuticals are regularly checked for authenticity, "home" remedies rarely are. "Snake oil" was thought to be a cure-all in the 19th century but despite the fact that you can get oil out of a snake, most of the "snake oil" salesmen were probably not selling anything more exotic than corn oil.

This is another situation where Cuddy could have used some help, particularly from one of her numerous oncologists. Oncologists have to deal with these issues all the time as many cancer patients seek "miracle cures" outside of medicine that often interfere with their medical treatment.