title: "Might" or "suggest"? No wording approach was clearly superior in conveying the strength of recommendation.
abstract: OBJECTIVE
  To compare different wording approaches for conveying the strength of health care recommendations.
  
  
  METHODS
  Participants were medical residents in Canada and the United States. We randomized them to one of three wording approaches, each expressing two strengths of recommendation, strong and weak: (1) "we recommend," "we suggest;" (2) "clinicians should," "clinicians might;" (3) "we recommend," "we conditionally recommend." Each participant received one strong and one weak recommendation. For each recommendation, they chose a hypothetical course of action; we judged whether their choice was appropriate for the strength of the recommendation.
  
  
  RESULTS
  The response rate was 77% (341/441). Most participants, in response to strong recommendations, chose hypothetical courses of action appropriate for weak recommendations. None of the wording approaches was clearly superior in conveying the strength of a recommendation. However, different approaches appeared superior depending on the strength and direction (for or against an intervention) of the recommendation.
  
  
  CONCLUSIONS
  No wording approach was clearly superior in conveying the strength of recommendation. Guideline developers need to make the connection between the wording and their intended strength explicit.
authors.affiliation: Department of Medicine, State University of New York at Buffalo, Buffalo, NY, USA. elieakl@buffalo.edu
authors.forename: Elie A
authors.initials: EA
authors.lastname: Akl
authors.forename: Gordon H
authors.initials: GH
authors.lastname: Guyatt
authors.forename: Jihad
authors.initials: J
authors.lastname: Irani
authors.forename: David
authors.initials: D
authors.lastname: Feldstein
authors.forename: Parveen
authors.initials: P
authors.lastname: Wasi
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Shaw
authors.forename: Terry
authors.initials: T
authors.lastname: Shaneyfelt
authors.forename: Meredith
authors.initials: M
authors.lastname: Levine
authors.forename: Holger J
authors.initials: HJ
authors.lastname: Schünemann
mesh_terms: D000328:Adult; D002170:Canada; D016009:Chi-Square Distribution; D019317:Evidence-Based Medicine; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006333:Heart Failure / Q000188:drug therapy; D006801:Humans; D007396:Internship and Residency; D043183:Irritable Bowel Syndrome / Q000188:drug therapy; D007802:Language; D008297:Male; D010565:Persuasive Communication; D017410:Practice Guidelines as Topic / Q000592:standards*; D012044:Regression Analysis; D014481:United States