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The pragmatism concept is controversial and there are questions about whether pragmatic trials should replace or complement them. Schwartz and Lellouch1 made an distinction between explanation-based studies, which confirm the validity of a physiological or clinical hypothesis, and pragmatic trials, which inform policy and practice decision-making. They also suggested an approach to pragmatic trials, dubbed PRECIS.2 This tool was designed to define the elements of a practical trial, including recruitment, design and delivery of the intervention, and follow-up. There is a positive increase in the number pragmatic trials published. A recent Medline search using the keywords naturalistic and pragmatic, limited to controlled trials randomized to control (RCTs), yielded 34 articles, which are shown in red in Figure 2. This is a sign that the health science community is becoming more sensitive to the subject of pragmatic thinking. However, it is important to keep in mind that the majority of these studies were conducted in primary care settings.