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Schwartz and Lellouch1 suggested a distinction between explanatory trials, which confirm a physiological or clinical hypothesis as well as pragmatic trials, which inform the practice and policy decisions. They also suggested a framework known as PRECIS for pragmatic trials.2 This tool attempted to define the elements of a pragmatic study, including recruitment, design, delivery of the intervention and its follow-up. The number of pragmatic trials is growing. A recent Medline search using the keywords naturalistic and pragmatic, which was limited to randomized controlled trials (RCTs), yielded 34 articles, as shown in red in Figure 2. This suggests that the health sciences community is becoming more aware of the importance of pragmatic thinking. However, it is important to remember that the majority of these studies were conducted in primary care settings.