The article by M Hassan Murad, Noor Asi, Mouaz Alsawas, and Fares Alahdab challenges the traditional hierarchy of medical evidence, particularly the placement of systematic reviews and meta-analyses at the top of the evidence pyramid. They argue that this placement is overly simplistic and does not fully capture the complexity of evidence evaluation. The authors propose two modifications to the traditional pyramid: 1. **Grading of Recommendations Assessment, Development and Evaluation (GRADE) Framework**: The first modification involves changing the straight lines separating study designs to wavy lines to reflect the GRADE approach, which evaluates the certainty in evidence based on multiple factors, not just study design. This acknowledges that methodological limitations, imprecision, inconsistency, and indirectness can affect the quality of evidence. 2. **Systematic Reviews as a Lens**: The second modification suggests removing systematic reviews from the top of the pyramid and using them as a tool to appraise and apply evidence from other study designs. This approach emphasizes that systematic reviews and meta-analyses are tools for consuming evidence, rather than being at the pinnacle of the hierarchy. The authors argue that these modifications help address challenges such as heterogeneity in meta-analyses and the methodological intricacies of systematic reviews. They also highlight the importance of these changes in re-evaluating the quality of evidence and the strength of recommendations, which are crucial for patient care. The new pyramid can serve as a teaching tool to explain the evolution of evidence-based medicine and the modern understanding of certainty in evidence.The article by M Hassan Murad, Noor Asi, Mouaz Alsawas, and Fares Alahdab challenges the traditional hierarchy of medical evidence, particularly the placement of systematic reviews and meta-analyses at the top of the evidence pyramid. They argue that this placement is overly simplistic and does not fully capture the complexity of evidence evaluation. The authors propose two modifications to the traditional pyramid: 1. **Grading of Recommendations Assessment, Development and Evaluation (GRADE) Framework**: The first modification involves changing the straight lines separating study designs to wavy lines to reflect the GRADE approach, which evaluates the certainty in evidence based on multiple factors, not just study design. This acknowledges that methodological limitations, imprecision, inconsistency, and indirectness can affect the quality of evidence. 2. **Systematic Reviews as a Lens**: The second modification suggests removing systematic reviews from the top of the pyramid and using them as a tool to appraise and apply evidence from other study designs. This approach emphasizes that systematic reviews and meta-analyses are tools for consuming evidence, rather than being at the pinnacle of the hierarchy. The authors argue that these modifications help address challenges such as heterogeneity in meta-analyses and the methodological intricacies of systematic reviews. They also highlight the importance of these changes in re-evaluating the quality of evidence and the strength of recommendations, which are crucial for patient care. The new pyramid can serve as a teaching tool to explain the evolution of evidence-based medicine and the modern understanding of certainty in evidence.