Thirteen's outlook on life:

"Here's the dirty little secret. I just think we are who we are, and I think lotteries are stupid."

―Changes

Changes is a 7th season episode of House, the twentieth episode of the season, which first aired on May 2, 2011.

Arlene Cuddy returns and House and Cuddy 's jobs are in danger when Arlene threatens to sue the hospital. Cuddy, House, and Wilson decide that appeasement is the best course of action, but when they take a conciliatory approach, Arlene's demands for compensation keep escalating. Meanwhile, House and the team treat a recent lottery winner who has reunited with an old girlfriend who Thirteen thinks is just interested in the patient's new found wealth.

Throughout the episode, the characters explore the ability of the other characters to undergo fundamental changes in their personality. Most of their efforts focus on the patient Cyrus, whose lottery winnings seem to give him the greatest hope that his life will change. However, by the end of the episode, it all seems that they have fallen back into old patterns, except for the fact that Cyrus once again seems to have found hope not by looking forward to the future his lottery winnings seem to offer him, but into the past to the one time he was happy. It's left to the viewer to determine if Cyrus will once again find the love he had two decades before.

However, the other character seem to have less luck. Chase has stopped sleeping with several women a week and claims to be happier as a result. Every effort to break his vows come to naught, but by the end of the episode, he has returned to his pattern of meaningless sex. Foreman insists he is not the rage machine he is always made out to be, but his efforts to control his temper turn out to be fruitless despite pharmacological intervention.

The character holding out the most hope is Arlene Cuddy, who believes her daughter's problems forming relationships would come to an end if she would just accept her affection for House despite all his flaws. Knowing that the two care about each other, she hatches a plot that, if it succeeds, will turn both of them against her in a last ditch attempt to drive them back together. However, when House figures out her scheme and she realizes she has failed, she has to admonish both of them that the real problem is that neither of them are willing to admit they made a terrible mistake and that the only chance they have to form a real relationship is with each other.

A man arrives at a house with flowers. An attractive woman answers, but tries to brush him off. He says he is looking for someone named Jennifer Williams he knew 23 years before, but she just shuts the door on him. The man crosses a name off the list, walks back to his limo and the driver, his cousin, tells him he's wasting his time looking for a past love. All of a sudden, the man collapses and says he can't move his leg. The limo driver shouts at the woman to call 911.

House tells the team that the man has partial paralysis, but there doesn't seem to be anything wrong with his brain. Taub reads the chart and realizes the patient just won $42 million in a lottery. He and House argue whether that much money can prevent misery. As they discuss the differential diagnosis, Cuddy comes in to tell House that her mother's lawyer has called threatening to sue the hospital. House orders an environmental scan and medical history and returns to his office to discuss the matter with Cuddy's mother. It turns out that the lawsuit is probably because Cuddy and her mother had a fight because her mother's new hip replacement is making her far less mobile and Cuddy wanted her mother to live with her until she got better. Cuddy reminds House how badly he acted during her case and that the mother insists on dealing with both Cuddy and House. However, House refuses to attend the meeting.

The patient tells the doctors he hasn't changed his lifestyle and he doesn't use drugs. However, the patient eats a lot of canned food. Meanwhile, Chase and Foreman are at the patient's old workshop discussing Cuddy's mom's threat to sue. Chase tells Foreman that he has to be less repressed. Chase then reveals he hasn't slept with a woman for over a month because he wants to be ready when the right woman comes along. Chase challenges Foreman to go through one differential without letting anyone get under his skin. Foreman points out that Chase has already said he represses his feelings so he can't prove people aren't getting under his skin. Chase says that he will just have to let that fact eat at him too. Chase finds a can of solvent.

Taub thinks that the canned food points to heavy metal poisoning, but Chase thinks he inhaled a toxin. Thirteen points out that the treatment for both is chelation. However, House orders forced urination for heavy metals and, if that doesn't work, dialysis for solvent inhalation. When the team objects and Foreman gets upset, House reminds them that chelation won't tell them what the real diagnosis was so they can prevent re-exposure. Foreman gives in.

However, Thirteen decides to go with chelation anyway. She figures House won't check and they can just flip a coin. However, when she arrives at the patient's room, she has found that Cuddy has withdrawn House's hospital privileges.

Cuddy's strategy is to force House to the bargaining table with her mother. Instead, House discharges the patient. Thirteen explains to the patient that it will only be for a few minutes until Cuddy folds. However, the patient sees an attractive woman and tells his limo driver and the doctors to shut up. The woman is Jennifer Williams, his old sweetheart. She admits she heard about his lottery win. They go to hug, but the patient vomits even though he doesn't feel nauseous. Thirteen realizes the patient is having a focal seizure and can't be discharged.

The patient obviously has a brain issue, but both of their previous diagnoses have to be wrong given the new symptom. Cuddy comes in to negotiate with House to get him to meet her mother, but they can't come to an agreement. Cuddy says she doesn't care if he treats his patient or comes to the meeting and walks out.

To prove to Foreman that he's a "boiling cauldron of repressed rage", Chase hooks up Foreman to a blood pressure monitor. House insults Foreman's diagnosis of Lyme disease, his ex-girlfriend, and brings up his brother Marcus Foreman, but Foreman's blood pressure stays steady. The team gets back to the differential. Taub and Thirteen discuss about whether finding his old girlfriend was a good thing. Thirteen finally suggests herpes encephalitis. House agrees and orders tests to confirm and treatment. He also reveals he removed the leads to Foreman's blood pressure cuff. Foreman was faking the monitor results. Foreman obviously gets angry and gets up to leave. House talks with Thirteen about the fact she now shares his view that life is miserable.

The patient and Jennifer are laughing together, but Thirteen tells her that she is going to have to leave the room for the test. Jennifer says she has to get home the next morning. The patient offers to put her up in a hotel, but Jennifer is reluctant. She does agree to stay for another couple of nights in her own motel.

House goes to see Wilson about the patient. Wilson agrees that it's probably cancer and that the patient's symptoms are caused by paraneoplastic syndrome. However, House is really there to see why Wilson isn't mad at him for not meeting with Cuddy's mom. Wilson says that he's supporting House because he's right - both Cuddy and her mother are trying to use House to get in the middle of the argument they are having. However, House thinks Cuddy insisted on him being there so he wouldn't come to the meeting and that Cuddy really doesn't want him there.

Cuddy's mother and her lawyer come in to meet with Cuddy. The lawyer asks where House is, but Cuddy tells them that it's not really about House, but about the fight she's having with her mother. The lawyer won't leave the room, but Cuddy's mother tells him to leave. Cuddy's mom tells her it's not about the fight they had. She wants $30, 000 to hire help while she recovers and put in a stair lift. Cuddy tells her that if she gives in, the Board of Directors will investigate and both she and House could lose their medical licenses. House finally arrives and threatens to put her old hip joint back in. Cuddy's mother leaves and says she will get a judge to take her seriously.

While they do a CT scan of the patient, Foreman tells Taub he faked his blood pressure because he had a lot of salt with breakfast. Taub thinks Foreman is repressed too and thinks it's good that Chase has stopped sleeping around. They find a tumor, and quickly find two others. It appears he has three completely different types of cancer.

Wilson is calling House an idiot for breaking into the discussion and accuses him of going there just because Cuddy tried to trick him not to. Wilson tells House he's going to force him to meet with Cuddy before Cuddy's mom files a lawsuit.

Chase hooks Foreman up to the blood pressure monitor again and then takes an oath that Foreman has not screwed with it. When House suggests making the patient's tumors grow faster, Foreman's blood pressure shoots up and although he's acting calm, it's obvious he's slowly getting out of control. He rips off the monitor cuff and Thirteen suggests he make out a will. House finally goes ahead with his plan to make the cancer grow faster. He also has a surprise for Thirteen - her high school boyfriend is waiting outside his office. Thirteen tells House that Ricky dumped her after she slept with his sister. House tells her to let him down gently.

Taub and Thirteen go to the patient to get consent. The patient asks Jennifer to marry him. She tells him he only thinks he loves her and they need more time. However, Thirteen is suspicious - Jennifer says she only came for one night, but she's wearing different clothes every day.

House finds Foreman doing yoga on the office balcony. Foreman says he needs to get a hooker for Chase. He asks why House keeps riding him, but not Chase. He tells him it's because he can make Foreman mad, but he can't make Chase horny. He tells Foreman to embrace Zen because he can't do anything about his own anger or Chase's libido.

Wilson and Cuddy corner House in a patient room. Wilson wisely put a tracker on House's portable television. Cuddy and House get into an argument about their break up. Wilson reminds them that it's both of their fault. He tells them that he's driving them both to Arlene's house so that Cuddy can write a check and House can apologize. He threatens to cut off House's Vicodin and House caves.

The patient's showing no new symptoms, and he challenges Thirteen's belief that Jennifer is just after his money. The patient says his hope that he would win the lottery and reconnect with Jennifer was all that kept him going. Now, he's halfway there. He tells her that she can't stand to see anyone happy.

Wilson, Cuddy and House arrive at Arlene's house. Cuddy gives her a check and House ekes out an apology. Arlene asks for more money to change her will to cut Cuddy out. Wilson tries to be conciliatory, but Cuddy and her mom get into another fight. Cuddy's mom rips up the check.

Foreman sees Chase sidling up to a new nurse. However, Foreman has already paid her $100 to slap Chase once he propositions her. However, when it appears Chase is about to close, nothing happens and the nurse comes over, gives back the money and slaps Foreman instead. Chase sees Foreman and waves at him.

Taub does an ultrasound while the patient discusses his will. Jennifer tells him that she doesn't need anything and encourages him to give the money to his family or favorite charities. However, although they've been pumping him with drugs to make the three tumors grow, they all shrank instead.

Foreman tries the blood pressure monitor again. As they go through a new differential, Foreman's blood pressure rises again and he insists it can't be right. When they press the matter, Foreman tells them he took beta blockers to keep his blood pressure low. Chase admits he was rigging the last two tests. House insists on a diagnosis of amyloidosis and orders a biopsy to confirm and chemotherapy to treat.

Cuddy quadruples House's clinic hours. House goes to the clinic and starts making a nuisance of himself. Wilson comes to commiserate. He also tells House that Cuddy's mom wants to meet again, but he realizes neither Cuddy nor House want to meet her. Wilson tells House that he's being obstinate because he doesn't want Cuddy out of his life and he is willing to have bad interactions instead of living with no interactions. He reminds him that he's not risking just his job, but any future relationship he might have with Cuddy.

The patient gives his cousin a cheque for $10 million because Jennifer had reminded him that he was the person who was with him year in and year out all their lives. When Jennifer starts crying, Thirteen realizes she's wearing tinted contact lenses under her glasses. The patient realizes that "Jennifer" doesn't have brown eyes and starts questioning her. He starts to realize she's not the woman he was in love with. He realizes his cousin has been coaching "Jennifer" to con him out of his lottery money, by convincing him to write a check to his cousin who has always been there. He throws them both out. He admits to Thirteen she was right. All of a sudden, the patient starts crashing.

The patient suffered a cardiac arrest along with failure of the lungs and liver before they even had a chance to start chemotherapy, ruling out amyloidosis. All of a sudden, they hear an evacuation alarm.

Everyone is outside with Cuddy trying to direct everything when her mother shows up. She says it was the only way to get Cuddy and House together. Cuddy tells her staff that they can reopen the hospital. The mother tells Cuddy and House she is going to file her lawsuit that day. Cuddy and the mother get into another argument. Finally, House pipes up and tells the mother that he and Cuddy are not getting back together. When Cuddy asks him what he's talking about, he tells her it's the only explanation for her mother's behavior. She's trying to get him and Cuddy to unite against her. Cuddy insists that her mother is just acting out of anger over a long series of perceived slights, but when she looks back at her mother, it becomes clear House was right. She tells them they're idiots and neither one of them is going to find anyone else who will put up the other one. Cuddy realizes that when she asked her mother to move in with her, the mother realized that she and House weren't going to reconcile. Cuddy tells her it will take more than a common enemy to get her and House back together. Arlene tells her that her standards are impossible. House has already left.

House goes to see the patient - the talk of a common enemy made him think of something. The patient has a teratoma, a usually harmless type of congenital growth that just contains cells that aren't where they're supposed to be. However, his teratoma contains brain cells, which have spread and caused brain symptoms. Some broke off and grew new tumors, but they grew so fast they collapsed. He just needs surgery to remove them.

Chase and Nurse Laura are seen in bed together. Foreman is still trying to relax. The patient is recovering after his surgery when the real Jennifer comes to see him. Thirteen and House see her with the patient and they agree that it will end horribly for the patient, but he will always have hope and be happy. House suggests to Thirteen that she's miserable not because of any predisposition, but because of the death of her mother, brother and her own illness. Thirteen tells him he's probably unhappy because of his failed rehab, failed relationships, and painful leg.

Teratomas appear in about one out of every 40, 000 people but are usually asymptomatic.

• The Jersey Shore is a 127 mile long coastline where New Jersey meets the Atlantic Ocean running from Sandy Hook to Cape May. The entire length is covered with resorts and tourist attractions, most notably those in Atlantic City. Once one of the most popular tourist destinations in the Northeast, it has declined over the past several decades as more southerly locations became easier to reach by road.
• "Beads from Thailand" are, of course, a euphemism for anal beads.
• House insults Foreman's diagnosis of Lyme disease, his ex-girlfriend and his brother in order to boost his blood pressure. When House said then he shared a motel room with his ex-girlfriend, the ex-girlfriend actually refers to Thirteen since, in The Dig, House did share a room with Thirteen in a motel after Thirteen's release from jail.
• "Khloe" is most likely a reference to Khloé Kardashian, the youngest of the Kardashian sisters.
• House's reference to Foreman turning green and bursting out of his shirt describes the Hulk.
• Good Cop/Bad Cop is a negotiation and interrogation technique.
• The reference to salt with breakfast notes that high sodium levels often drive up blood pressure.
• Taub refers to the uniform used in Star Fleet in Star Trek (The Original Series) and the fact that none of the character's clothing was ever different at any point in its three year run.
• Zen is a form of Buddhism that stresses rigorous meditation, insight into the nature of Buddha, and self-insight.
• The remark about turning it "up to 11" is from the movie This Is Spinal Tap.
• Wile E. Coyote is the antagonist of the Road Runner (Wile E. Coyote and The Road Runner).
• "Bitch to king four" and "Checkmate" are allusions to Chess.
• "The Godmother" and "consiglieri" (advisor) are both references to The Godfather.

• An EEG is useless when trying to diagnose herpes encephalitis. It's usually diagnosed with a lumbar puncture, which Cyrus had already had which would have ruled out the condition.
• In real life, a teratoma probably wouldn't cause these symptoms. If a teratoma did have three different types of cancerous cells within it, they most likely would have grown entirely within the teratoma instead of spreading through the body. In addition, brain tissue outside the brain wouldn't be recognized as "foreign tissue" by the body and would not provoke an autoimmune response.
• Atherosclerosis does have numerous causes, but exposure to ceramics and precious metals aren't among the causes.
• Thirteen's idea to treat with chelation as a cure-all is faulty because the two different toxins involved need two different chelation agents. It would be dangerous to administer two in the necessary therapeutic dose and it wouldn't provide them with a definitive diagnosis.
• Cyrus has a full body CT scan to find the pancreatic tumor, but somehow it missed the other two that were there as well.
• Most natives of New Jersey like Cyrus would most likely just call it "The Shore" rather than "The Jersey Shore", particularly when speaking to another person from the state.

Withdrawing privileges:

As we've seen before, Cuddy has followed through with a threat to cut off a doctor's hospital privileges in order to get them to finish their other duties (such as in Pilot to force House to do clinic duty). In truth, with a tenured staff member like House, the Dean of Medicine has very few other options to discipline a physician.

However, in this case, it appears Cuddy is the person abusing her authority, and as a result, puts the patient in the middle of the battle. House isn't being asked to do his job in this case, only to help Cuddy out of a jam (which, to be fair, House was involved in).

Technically, House could have appealed Cuddy's decision to the hospital's accreditation committee (which also works to discipline doctors within the hospital system), but given his history, Cuddy probably could have come up with dozens of accumulated reasons for taking the action she did, and House couldn't reveal the truth about Arlene without putting both of their necks on the line. However, in such a hierarchy, a Dean who systematically abused their authority could probably be called before the Board of Directors.

At least Thirteen and Taub do the right thing by explaining to the patient why House is threatening to discharge him. Technically, House could justify the move medically as Cyrus was stable. However, there was no real guarantee that Cuddy would cave given House's move so it probably would have been more appropriate to transfer Cyrus to another hospital instead.

Hiding malpractice:

Everyone's reaction to Arlene's threatened lawsuit (including Wilson's) is completely inappropriate. Insurance companies, hospitals and state medical boards all require physicians to immediately report any notice of a malpractice action even before there is a formal lawsuit. Arlene showing up with a lawyer is clearly an indication that the reporting requirements have kicked in, but even the phone call should have been sufficient for Cuddy to report the matter to the hospital's general counsel.

There are loads of consequences that follow. Malpractice insurers require notice of all claims (whether they result in lawsuits or not) so they can provide immediate counsel if necessary (Cuddy should have shown up with her lawyer too) and judge whether their reserves for payment of claims are appropriate (for bookkeeping purposes for the underwriters). In fact, failure to report the claim at this stage would have resulted in Cuddy, House, and the hospital losing the right to malpractice insurance. Although Arlene would have recovered the money from the insurer, the insurer would have chased after the hospital, Cuddy and House to make up the difference. The hospital would have summarily fired Cuddy and House for failure to report, and the matter would have to be reported to the state medical board, which could have resulted in disciplinary sanctions against both Cuddy and House. Wilson's not innocent either. Having known about the possible lawsuit, he instead brokered a private settlement to avoid the insurance company, which he could also have been disciplined for.