Patient relationships with the healthcare system can be complicated. Patients find themselves simultaneously working with and working against the healthcare system. This year has been the most exciting year for chronic illness that I have ever lived through. I use type 1 diabetes as a case study for the development of medical technology because diabetics have a long history of using personal medical devices. Patient developed closed loop systems, built on ‘hacked’ medical devices and open source software have entered the FDA approval process and are being tested by an unprecedented number of patients. How does this represent changing paradigms in medicine more broadly? Why are diabetics so riled up and what are the implications for other chronic illness communities? I will describe the current landscape of patient advocacy in terms of hot war (legislative) efforts and cold war (software & medical device hacking) efforts by diabetics.