Appreciated the thoughtful response from IDSA. It reflects shared concern that strong or highly directive statements should be used cautiously when evidence is weak, and a convergence toward aligning guidance with evidence strength and improving transparency in uncertainty, while continuing GRADE alongside structured clinical reviews. WikiGuidelines is acknowledged as having complementary strengths in this space. Continued dialogue and future collaboration remain open, with a shared focus on patient and clinical needs. #IDXposts

@ABsteward Agree with all. Except GRADE. GRADE has to go. It is the fundamental reason these guidelines continue to make strong recommendations absent data. A much more rigorous data standard must be used.

@BradSpellberg @ABsteward Why do you write : GRADE has to go?

@BoussageonR @ABsteward GRADE explicitly enables recommendations made on weak or no evidence. GRADE is the reason societal guidelines make such recommendations. GRADE endorses arrogance and must be replaced with an evidence standard that has the humility of uncertainty.

@BradSpellberg @BoussageonR @ABsteward Interesting thought. But isn’t GRADE exactly about categorizing this "uncertainty" of evidence? Or do you criticize the evidence-to-recommendation part?

@LGHemkens @BoussageonR @ABsteward No one needs GRADE to admit there’s no evidence. All you have to do is say, hi everybody, there’s no evidence. Not hard. GRADE explicitly enables recommendations when there’s no evidence. And that is its original sin. Amy system that allows and encourages that is failure.

@BradSpellberg @LGHemkens @ABsteward Dear Brad, I think the disagreement stems from how we define "evidence"... I agree with you. GRADE and its authors consider all epidemiological data to be evidence, even if it is of very low quality. See my discussions with Lars and David x.com/i/status/20371…

@BoussageonR @LGHemkens @ABsteward No that is the isn’t the disagreement. Pure and simple, GRADE enables recommendations even if there is no evidence, just opinion. And that is wrong. Period, end of story.

@BradSpellberg @LGHemkens @ABsteward No, GRADE says "low quality of evidence " is evidence... You says this is" hypothesis generating evidence."...ok, for logic of research... I say this is "lack of evidence" for decision-making....for logi of care I think it's high time we created the PROOF based medicine !

@BoussageonR @LGHemkens @ABsteward That’s not the point at all. Don’t over complicate. This is very simple. If something is proven true with reproducible prospective controlled studies, make a recommendation. If not, don’t. It’s really that simple.

Isn’t this a bit too strong? GRADE clearly has issues, but saying that only prospective controlled trials should count as evidence seems like a kind of epistemic fundamentalism. There has to be a path for accepting other types of evidence when prospective controlled studies are infeasible, unethical, or not yet complete. There are lots of decisions physicians have to make with limited evidence and there needs to be a pathway for physicians practicing away from major centers to know what most of their colleagues would do in a certain situation. Do we just have a different outlet for that information?

@austingmeyer @BoussageonR @LGHemkens @ABsteward I wish people would actually look at WikiGuidelines so you can visualize the point. Because people keto missing the point. Do not create a universal standard of care, which is what guidelines do with recommendations, whether they like it or not. In the absence of such level of