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The concept of pragmatism is controversial and there are doubts about whether pragmatic trials should replace or complement them. Schwartz and Lellouch1 suggested the distinction between explanatory trials, which validate a physiological or clinical hypothesis, and pragmatic trials that inform the practice and policy decisions. They also proposed the framework for pragmatic trials, called PRECIS.2 This tool was designed to define the features of a practical trial which includes recruitment, design and delivery of the intervention, and the follow-up. The number of pragmatic trials is growing. A recent Medline search using the keywords pragmatic and naturalistic, restricted to controlled trials randomized to control (RCTs) produced 34 articles, shown in red in Figure 2. This suggests that the health sciences community has become more aware of the importance of pragmatism. It is important to keep in mind that the majority of these trials were conducted in primary care settings.