Now you've mentioned there's two parts for grade. Certainty of evidence and then moving from evidence to recommendations. Just a few details about how grade does the certainty of evidence part. Sure.

I again could explain how I do this in teaching. So grade is appraising a body of evidence and as an example a trust-worthy guideline has to base recommendation on systematic review. So typically there's a systematic review showing the best body of evidence to inform a particular question. And the output of a systematic review is typically a meta analysis of different trials looking at the effects of a treatment, for example. And when I teach EBM now to medical students or doctors, I say, okay, let's have a look at this meta-analyses and tell me what the results are. And that has always been a key question in critical appraisal. And they may or may not be able to understand those results. But once we have explained the results, I ask them, well, is there anything here that make you lose confidence in these estimates of effect you're looking at? And we opened up for a discussion. And most doctors would think about applicability as this evidence relevant from my patients. Now, that's what we call indirectness in grade. And I could explain the concept of indirectness, one of the five factors in grade. And then somebody may argue, hey, it looks like these studies are showing different results. They're all over the place. That's what we call inconsistency with grade heterogeneity. And some others may say, oh, these lines around each trial or this diamond at the bottom seems very imprecise. That's the third concept to grade. And then somebody may question the quality of each trial in this meta-analysis, that's risk of bias. And then finally, publication bias may come to mind. So actually, when I teach EBM to clinicians now, I try to let them think on their own, but in the end, I could outline that grade, critical appraisal, rating certainty of evidence, is about those five factors, risk of bias, inconsistency, indirectness, precision, and publication bias. And to me, that has always been part of critical appraisal. It's just that it's much more systematic, transparent for each patient, important outcome. You go through this and you have to end up with a certainty rating. Again, I think it allows those who read systematic reviews or look at a guideline and evidence summary to understand the judgments made. They may challenge it. It's transparent and it's systematic.