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Post by stevil on Jan 10, 2019 17:14:27 GMT -5
With my clients I’ve seen this over and over again, it’s like they create drugs for drugs, they put you on a high blood pressure medication and then they put you on a drug for the side effect of that and then they put you on Viagra because by the time you get done with all those other drugs nothing is working. My Blood pressure was 120/80 when I was in my 30s now it’s 116/65. I spend a good part of the time working with clients to get them off all these drugs. The first line treatment for hypertension is diet and exercise. The problem is that our culture is ever more demanding of a silver bullet. I don't want to change, just give me a pill and make it better. The values of the docs that practice evidence-based medicine align with yours.
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Post by stevil on Jan 10, 2019 16:46:40 GMT -5
Stevil is getting himself in trouble with me again.. If we are expected to accept the world we live in then I think HE needs to accept the board he posts on. I don't know about anyone else .. but I'm NOT going to accept what doctors are doing.. they take an oath to do no harm and yet ignorantly close their minds... I don't think that type of attitude has anything whatsoever to do with trial data but rather the choices they are making.. If we on this board can see the glaring truth.. so can they.. don't want to hear anymore excuses for this behavior or our healthcare system as it stands which cares more about money then the patients. OH and.id rather see a less educated NP who has an open mind and listens to me the patient than an arrogant doctor who ignores me. I think you're completely misunderstanding me. I'm not saying to accept the way things are, necessarily. By all means, be proactive. Be the change you wish to see. If you see injustice in the world, please do try to change it. However, there are flaws in any system. Solving one problem usually creates another. The goal is just to make the next problem smaller than the one before it. I do accept that I am on a MNKD message board. I don't come here to upset people. I try to be as honest as I can be with the knowledge and experience that I have- unfortunately, I just don't have a lot of good news to share. I'd rather be honest, bring bad news, and be hated than deceive, bring good news, and be adorned by all. Look no farther than our political system to see why. It's all about perspective and this is something I'm not sure I can properly convey through words. I think I am at the limits of language and experience is required in order to understand what I'm saying. It's not that doctors cannot see the glaring truth, it's that the glaring truth is not being presented to them. Doctors do not scour the internet for tweets of people taking medications. They do not frequent message boards for medications. There are literally hundreds of new medications that come out every year. There's not enough time in the day to follow them all. The ones that stand out get noticed, the rest blend in with the crowd. To keep beating the poor horse that probably has nothing left to hit, doctors aren't seeing good data from the trials. The results have been mediocre at best. The only reason I'm aware of Afrezza is because I was interested in investing before I got into medical school. Afrezza was included in my insulin education in medical school, but it was more of a footnote because, based on trial evidence, it's a bench-warmer, not an all-star. I agree with you that the healthcare system cares more about money than patients. Unfortunately, I see this happen nearly every day. The people with more money typically get better care. Those that don't have money are at the mercy of state medicaid and have few options, comparatively. This is one of those things I was talking about above. Socialized medicine is not without its warts, either. It's all about what people are willing to tolerate. America, so far, has chosen it prefers the warts of privatized medicine. I don't think it's fair to demonize physicians because their hands are tied based on what their patients can(not) afford. I have worked with a lot of doctors that are just as frustrated as you are. I'm not sure what I said that was arrogant? If it was in regards to NP's, I think they're great for what they do. Depending on the practice, NPs usually don't see new/complicated patients but manage the maintenance and routine patients that already have an established plan (if outpatient) or they have a doctor cosign their work (if inpatient). You generally do not see NPs have independent practices. They usually share office space (outpatient) with Drs or are apart of a physician-lead group (inpatient). It's not a knock on them... I do not currently, nor will I ever view an NP as being an inferior human being. I actually think it would be unfair to hold them to the same standards as a physician (as do their medical boards). I do not expect them to have the same level of knowledge because their training is more experience-based vs academic. They are very good at seeing the routine things, but get stumped when atypical or rare diseases emerge or if there are complicating factors to standard presentations or therapy. My post was in no way meant to look down on NPs. It was simply to point out that they're generally not trail-blazers because they follow established algorithms. When you don't understand the science, it's difficult to get creative and deviate from protocols. There are some NPs that do independent research and are very knowledgeable. However, it's by far the exception and not the rule. The kicker with that, though, is whatever research an inquisitive NP does, it's likely similar information to what doctors see. Also, remember that NPs can prescribe Afrezza. I'm surprised (and curious as to why) they're the heroes in this scenario when they are just as much a part of the prescribing problem. Unrelated, it saddens me that this one mistake (even if it is a big one) is getting so grossly magnified on this board. Doctors are not perfect and expecting them to be is an unfair expectation. I'd like to think that they typically get things right over time (which is a fair expectation if attainable), but I'm bummed by those who have become embittered towards the entire population of doctors because they've become better informed on a drug through the use of unconventional methods. Medical boards do not hold doctors responsible for the ins and outs of every drug. It's just not possible, nor is it really necessary. Even in the case of Afrezza, knowing the mechanism would change very little by itself. Doctors would still want to see evidence that it works the way it should on paper and doesn't cause any other problems along the way due to its unique profile. Newton's 3rd law is especially important in medicine as the body is one single entity composed of an infinite amount of moving parts. One small tweak to one part can throw the whole system off. To put it more simply, the only things doctors care about with drugs are: 1.is it safe and 2. does it work. The mechanism is useful only to prove points 1 and 2 true. In conventional outlets-the information that doctors are responsible to know- doctors haven't seen points 1 and 2 create a compelling enough of a story to prescribe. In my opinion, it would only be fair to judge if that time comes and still nothing changes. cretin11 I think I answered your question. Let me know if it's still unclear. I appreciate the appreciation. I try to help people, even if it's not what they want to hear...
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Post by stevil on Jan 9, 2019 7:49:29 GMT -5
Doctor's are human beings. Doctors can be fallible and arrogant. We need to de emphasize the importance of the all knowing doctor and the 8+ years of schooling/training. 1. Increased use of computers, internet and AI. 2. Empowerment of nurses and NP’s 3. New positions to de-centralize decision making away from specialists. Now this is when doctors (established interests) tell me I don’t know what I’m talking about. I’m not following your rationale. Doctors are human beings and are fallible, sure. That’s the world we live in though. No one is perfect. That includes AI. Who do you think is responsible for programming AI? If you think AI won’t make any mistakes, you will be disappointed. AI will likely make fewer mistakes, but until technology advances, all they can do is follow their programmed algorithms. The human body is so complex that I’m not convinced a machine will be able to replace a human being for quite some time. After all, it’ll still rely on a human to input the history of the illness because not every disease has a known biomarker. Some diagnoses are still based on clinical judgement. Empowerment of nurses and NPs and decentralization of specialists- I’m not following this at all. Why would you want to take medical decision making away from the most educated and replace it with the less educated? NPs are great for what they’re able to do, but Who would they then turn to if we no longer had specialists? Humans are fallible and don’t know everything, so why would you want to cripple the ones that are your best shot at being healed? I worked as a tech in the operating room before going into medical school. The other techs I worked with always complained about the nurses and how lazy they were and how they always were shirking off their responsibility. I didn’t join in on their misery, mostly because I think it’s a waste of energy, but once you have a view from the other side, your perspective changes. The reason the nurses seemed so lazy and always shirked off responsibility was because they were so busy doing their own job that they needed to delegate whatever they could that didn’t require their level of training. The same thing applies here. If you were to become a doctor, I think your perspective would change. Technically, I’m still not a doctor yet, so I still remember what it’s like to not be one. I think youre forgetting/not aware of a couple things. First, reliance on internet and AI would still yield no scripts of Afrezza. Unless you want the average person to establish standards of care, in which case, heaven help us. Second, NPs are allowed to prescribe Afrezza. Same as docs, no one is stopping them. Conveniently enough, I have a cousin-in-law who is a diabetes NP and she too does not like Afrezza, at least as of 3 years ago when I saw her last and was able to discuss it with her. She lives 2000 miles away so we don’t talk much. NPs don’t have as much of a scientific background, so they’re much less likely to understand or appreciate the characteristics of Afrezza. Their training is more algorithmic in nature because they don’t know the pathophysiology of diseases, they only know how to identify and treat some diseases. I don’t think you’ll be happy getting your wishes...
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Post by stevil on Jan 9, 2019 0:36:10 GMT -5
You guys we seem to have this argument over and over, I don’t know about all the scientific stuff, all I know is that everybody I’ve ever known that’s been on Metformin is sick to their stomach off-balance and have a hard time feeling their feet. You put them on Afrezza and they feel like they’re not diabetic. That they have their life back! The reason this argument is had over and over again is because some posters refuse to accept the answers to their questions. There are several posters who repeat themselves over and over, seemingly to wear the other side down just to claim victory of a war no one but them cares to fight. It’s a war of attrition. No matter how valid the claim, nothing said on this board carries any significance in the real world as far as medical practices are concerned. If that were the case, Afrezza would be the best selling drug of all time. Frankly, these conversations are a waste of time. I come to give perspective for those who care to have it- For those with ears, to let them hear... I’m not defending the actions of doctors, I simply try to explain why they do what they do. I’m on the front line of the battle that’s being fought in the real world, so I feel I am uniquely qualified to speak into certain situations because of my training and the conversations I’ve had with different doctors at different hospitals/clinics who came from different parts of the country, and went to different medical schools. When you hear slight variations of the same story from complete strangers over and over again, it’s not coincidence. When they tell a story that makes sense (why they don’t prescribe) and aligns with reality (low script count), it becomes even more believable and trustworthy. We’re stuck in a chicken or the egg scenario. Patients can’t get their lives back until doctors prescribe it and doctors won’t prescribe it if they don’t see patients get their lives back. With all of that amazing data Dr Kendall is sitting on, it’s sure taking him a really long time to bring it to light. All I can say is the floodgates would open up if doctors saw trial data to support VDex’s claims in a reputable publication. Look at what happens with GLP-1s when there is data to support their use. Just imagine if the full benefits of Afrezza were highlighted. There would be no comparison and no doctor would have a reason to prescribe anything else, save cost. Unfortunately, until that data surfaces, it will be status quo.
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Post by stevil on Jan 8, 2019 22:43:49 GMT -5
I’m with vdex. I don’t see hockey stick in the near future. Consumers will not drive that type of growth. Every doctor I’ve spoken to that knows about Afrezza has told me it’s unsafe, ineffective, and “expensive garbage.” It would take patients demanding Afrezza from doctors and that rarely ever happens. No ad campaign will change that. If you want hockey stick growth, you need to win the doctors over. That’s the only way forward to exponential growth- once they have great success or are shown the road to success. Stevil - EVERY doctor? I highly, highly doubt this. How many doctors have you spoken to? Yes, every doctor I’ve spoken to that had heard of Afrezza. I have not yet run into a prescriber of Afrezza. On the flip side, the blank slates I’ve talked to, the ones I get to make the first impression on, say they’re impressed and they’ll follow the story once it gets better insurance coverage. The presentation I gave generated a lot of interest because I got to present Afrezza the right way. I showed why a faster insulin was needed by showing how much more area is under the curve of RAAs, why postprandial excursions are so vital to A1c, and how Afrezza could radically transform treatment with its tight control. I’ve probably spoken to 30 or so doctors about Afrezza. I’d say around 40% had heard of it. So, around 12 gave that opinion. I have yet to meet a doctor who both had heard of Afrezza and had a high opinion of it. Which is a shame because a couple were really interested in diabetes treatment and spent considerable time researching Afrezza. They came away unimpressed with the data that’s floating around out there.
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Post by stevil on Jan 8, 2019 9:40:40 GMT -5
I’m with vdex. I don’t see hockey stick in the near future. Consumers will not drive that type of growth. Every doctor I’ve spoken to that knows about Afrezza has told me it’s unsafe, ineffective, and “expensive garbage.” It would take patients demanding Afrezza from doctors and that rarely ever happens. No ad campaign will change that. If you want hockey stick growth, you need to win the doctors over. That’s the only way forward to exponential growth- once they have great success or are shown the road to success. Stevil, I understand expensive, but why do they think unsafe and ineffective? Mostly related to exubera. They think it might cause pulmonary fibrosis or cancer. But they sort of wrote it off as soon as they heard about it and didn't follow any safety updates... Without being confronted with new information, they're not going to seek it out. In medicine, for better or worse, doctors learn about medications in classes - ace inhibitors, ARBs, atypical antipsychotics, etc... The reason for this is that it allows for greater ease when picking a therapy. Whenever there is variation in a certain class- if one performs better in certain situations than the rest in their class- those unique characteristics are committed to memory, but they're still limited to their specific class because the mechanism is essentially the same. The problem as I see it is almost entirely in the way Afrezza has been explained to prescribers. This may be unfair because I've never seen an Afrezza drug rep on any of my rotations, but I'm the literature, they've done little to nothing to distinguish themselves from exubera. So it unfairly gets lumped into the same class as inhaled insulin. Next, the trials haven't displayed Afrezzas superiority. It takes more insulin to do less. So not only are you spending more money, but you're lowering your A1c to a lesser extent than RAAs. Part of that is packaging... But what's done is done there... Hard to change that now. But doctors haven't been trained to know that you need to dose more aggressively. There's a graphic on the prescriber page that you should dose 1.5 :1 but that gives off a feeling of ineffectiveness to the doctors I've talked to. So you're paying more per unit of insulin as well as having to dose 1.5 times as many units. They don't see the benefit. I really think it will take convincing trial data to turn the tide. I feel even more strongly about it when I consider they've been trying to sell Afrezza for 5 years and still haven't gotten far. It's not coincidence. I also don't think it's fear of losing money. I've met some bad docs that are only in the business of making money, but I know for certain that docs are looking for a way to better manage diabetes. They hate it and what it does to their patients. They just need good data to show them the solution is already out there.
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Post by stevil on Jan 8, 2019 0:15:23 GMT -5
I’m with vdex. I don’t see hockey stick in the near future. Consumers will not drive that type of growth. Every doctor I’ve spoken to that knows about Afrezza has told me it’s unsafe, ineffective, and “expensive garbage.” It would take patients demanding Afrezza from doctors and that rarely ever happens. No ad campaign will change that. If you want hockey stick growth, you need to win the doctors over. That’s the only way forward to exponential growth- once they have great success or are shown the road to success.
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Post by stevil on Jan 6, 2019 23:33:51 GMT -5
I have to disagree with the posts in opposition to bringing HbA1c down quickly. Let me admit that I'm not a doctor, but as the Founder of Vdex along with my very close physician friend, I get medical input on all aspects of Vdex, all the time. I have 3-4 different physicians that I can access quickly. All are in favor of attacking HbA1c levels aggressively. It is true when you bring someone from an A1c of 14 to 7 there is an adjustment period for their body, but that is brief. There can be some "symptoms" of hypoglycemia, but theses are transitory and not dangerous. It's just the body adapting to the new normal. However, the salutary benefits of a more rapid drop in HbA1c are huge. Some, such as much better sleep, really help reinforce the change and keep the patient motivated to improve. I think that in part explains the high compliance among Vdex patients. A subtle point is the issue of Afrezza's mode of action in reducing HbA1c. Because Afrezza attacks the post prandial excursions, or more accurately stated, preempts them, Vdex gets more bang for the buck with less danger. Here's why: the post prandial excursions where blood sugar levels skyrocket into the 300-400s and more for many patients, are what really drive up the HbA1c values. Since HbA1c is an average of lots of data points, if one eliminates the worst data one gets a bigger effect on the average than if one brought all data points down a small amount. In statistical terms, we're eliminating outlier data. Even if we don't address the basal data we still see a large effect on A1c. But, here's a key point: since we don't initially address the basal data, we haven't so dramatically changed the existing blood sugar state of the patient. I apologize for not making this clearer, but what I'm trying to explain is that there is a statistical effect that is not necessarily indicative of a physiologic effect. I've never seen this issue addressed in the literature but that may be because never had a product before that could do it. Just one more way Afrezza is ground-breaking How closely do you guys monitor electrolytes? I don’t understand how that aggressive of therapy wouldn’t throw them off...
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Post by stevil on Jan 5, 2019 22:15:05 GMT -5
I feel like I’m in an alternate universe. Are you not the same mango that told me to spend as much time as it took for patients to understand their disease process? Now you’re telling me docs don’t have time to do that? All in in good fun, mango. Ill be keeping an an eye on this and once I finish residency, will give it a closer look. I don’t understand their business model but would be willing to entertain it when the time comes. Well well well, stevil, I'm glad you were able to get a poke at me in this parallel universe. Care to share your presentation on Afrezza with us? Is it a poster? pics? It was a PowerPoint presentation. Nothing super fancy, but I started with CGMs and finished with Afrezza. I was on a medicine rotation and was allowed to pick any topic I wanted so I took the opportunity to talk about Afrezza.
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Post by stevil on Jan 5, 2019 14:29:43 GMT -5
I feel like I’m in an alternate universe. Are you not the same mango that told me to spend as much time as it took for patients to understand their disease process? Now you’re telling me docs don’t have time to do that?
All in in good fun, mango.
Ill be keeping an an eye on this and once I finish residency, will give it a closer look. I don’t understand their business model but would be willing to entertain it when the time comes.
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Post by stevil on Jan 5, 2019 12:00:15 GMT -5
I've been thinking since reading the latest VDex whitepaper. VDex might do well to consider adding another business model. Currently, as I understand it, individual doctors and/or business entrepreneurs can open VDex clinics and get support (e.g. training, materials) from the VDex parent company as part of their startup costs. Another business model that could become quite lucrative would be a model where VDex offers its services to Primary Care Physician clinics for VDex to handle the titrating and coaching of patients newly prescribed with Afrezza. I would set it up to be a monthly fee-based service with an annual contract. VDex would provide initial onsite basic training of clinic staff in regards to the benefits of Afrezza treatment for diabetes, followed by VDex itself remotely providing their proprietary titration protocol and daily 1-to-1 coaching for Afrezza patients. Initially this would involve VDex physicians but eventual coaching would be handled by other certified healthcare professionals at VDex. Clinics could choose whether to continue paying the annual service fee or to pay VDex to teach them their protocols. The contract would include a confidentiality agreement. VDex would have to secure additional funding for scaling up the marketing of it's proprietary treatment protocols, including initial travel & lodging expenses for visiting interested clinics and the initial onsite training, but this business model could quickly achieve cash-flow and become quite lucrative. I am NOT suggesting that doctors would find the service appealing because they are lazy or apathetic to the patient. On the contrary, the appeal of this business model would lay in the fact that contracted specialists would be preferred to hiring & training clinic staff for patient training on the use of a revolutionary new insulin treatment. It would also provide the clinic with 1-2 years of observing patient results, at which point they may pay VDex to train clinic staff to adopt the VDex protocols and handle patient treatment with their own staff. Perhaps, Sportsrancho, you would consider passing this idea along to your contacts at VDex? What's the monetary benefit to the PCP? They're spending more money to make the same amount. They can't bill insurance more money to cover VDEX's cut. This would work for cash payers, but I don't see it working for those with insurance. Would have to know how much nurse educators get paid by insurance companies to know whether it would be possible for VDEX to get their cut, doctors to get their cut, nurses to get theirs, then enough left over to cover overhead of space and supplies. I'm not sure there's that much money in it, but admittedly, I don't know.
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Post by stevil on Jan 3, 2019 23:03:20 GMT -5
By far the most oft used website/app used by the doctors I rotate with is UpToDate. Next is AAFP because their articles are succinct and easy to read, then DynaMed, although there are a lot of other good ones.
What’s so great about UpToDate is inherent in its name- it spends a considerable amount of resources making sure it has the most current information as more “trustworthy” articles get published. It’ll still make mention of the lesser-powered studies for consideration, but it does all the grunt work for doctors by collating all of the best studies in one place to provide the most current and complete information to make educated recommendations. There is no lack of information to learn in medicine and as much as some posters on here want to criticize doctors for not staying current, they need to direct their anger at the ones responsible for not putting convincing information in the locations doctors actually look to become informed. You can’t learn about what isn’t there.
The previous post gets to the heart of why I’m maybe too aggressive with some posters on here when they say anything other than strong studies and insurance is the reason for lackluster script growth. It has nothing to do with FUD or laziness by physicians. There simply isn’t any good data for doctors to consider once they hear about Afrezza.
The process goes like this: 1. Patient asks doctor if they’ve heard about a certain medication 2. Doctor says no, but I’ll do some research on it and get back to you 3. Doctor goes to UpToDate and sees nothing worthwhile about it.
Few doctors will allow their patients to prescribe carte blanche for themselves. I certainly haven’t come across any, unless it was a one time fill for the patient either for addiction or to get them through until an appointment with the specialist managing their care. But they definitely wouldn’t prescribe a new medication they weren’t familiar about without doing some research. If they do, they likely won’t have their license very long. My point is, even if a patient thinks Afrezza is the greatest thing in the world, it’s not a guarantee that they’ll be handed a prescription for it. Between all the wives tales and Web MDs out there, doctors usually don’t believe a word their patients tell them, especially if the patient is aggressive and makes demands. If there is strong rapport and a healthy relationship, I think you’d see a lot more scripts get written, but even then, what would most likely happen is strong pushback because the relationship is healthy enough for the doc to try to convince their patient to do what they think is in their best interest by avoiding Afrezza.
I presented about Afrezza in front of residents and attendings on my rotation last month and was stuck explaining the science and why it “should” work because I didn’t have enough data to prove that it “did”. It was quite eye-opening to say the least. I’ve become so familiar with Afrezza that I haven’t been doing any further research on it to see what information is actually out there. It was disappointing to say the least...
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Post by stevil on Dec 31, 2018 11:17:06 GMT -5
As a long time burned shareholder I agree with most of the comments here. Mike had an opportunity a year ago to get Afrezza distributed in UAE. When asked at the ASM what happened he said he would have had to deal with too many players. Perhaps he should have hired someone to do that for him. To me it was a bird in the hand and a willing partner with a huge market. Now he doesn't even speak of distribution there. He struck a deal with BIOMM with no cash & apparently no timeline for them to perform. Granted they have to deal with the approval agency in Brazil, but there is never any progress to report. Cipla is the same only in India. They should be reporting progress to him and he could at least give shareholders a rough idea of where Cipla is in the process and what a worstcase/bestcase time frame could be achieved. Tanner? Same thing. Nothing. If any of these deals hold water then some progress should be reported. Are all of these companies free from progress milestones without penalty? They should be jumping through hoops for access to Afrezza. These deals smack of the same poor structure as the offering. I would hope Mike enlightens us about the status of these and other objectives on the call or it isn't worth opening up the conference bridge. Just throwing something out as I have several friends and family members who own their own businesses. When you're a small small company with limited resources, more business isn’t always better business. Meaning perhaps those countries were going to have a lot of demands which would require far more resources within the company to make them happy than the typical customer. At some point, it’s just not worth the few extra dollars. A family member has experience in hospital administration and has worked directly with Saudi princes and the like from the Middle East. They are accustomed to getting everything on their terms- as far as demanding an entire floor be shut down in the hospital for their entourage. My guess is Mike couldn’t get a price he felt would be worth the headache of dealing with VIP clientele. At least that’s the part of me trying to give him the benefit of the doubt. He’d likely have to hire a few people just for those accounts and probably felt it wouldn’t be worthwhile at the end of the day.
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Post by stevil on Dec 3, 2018 17:46:48 GMT -5
A pulmonologist? I thought they did them in the endo's or PC's office. I would be surprised if an endo had a spirometer in their office, unless it was specifically for Afrezza. PCPs don't have to have it in their office, although some choose to. Just depends on the PCP. They probably wanted to be vigilant and have a pulmonologist sign off, or didn't have one in their office so they referred out.
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Post by stevil on Dec 3, 2018 17:07:16 GMT -5
"Believe me, I'm probably the biggest believer of Afrezza on the board." — stevil July 8, 2015 at 9:18AM Stevil, you are a hypocrite or a liar. Take your pick. I really don't enjoy getting into arguments with people that just make asses of themselves. It brings me no joy. This will be my last response for the sake of the board, moderators, and you. 1. I have not said anything contrary to that statement. You cannot make a claim without any evidence, i.e. pointing me to the post that gave you that impression. Although I think it would be necessary to dive into semantics and define believer because I will admit, you are far more radical than I am. But this was also before you joined the site (I think). 2. You pulled a quote from 3 and a half years ago. Really? Even IF I said anything contrary to that, am I not allowed to change my mind after 3 and a half years of medical school and time in general? Have you never changed your mind, ever, in your entire life? Would that not also then make you a hypocrite or liar?
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