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The idea of pragmatism is controversial, and there are questions about whether pragmatic trials can be used to replace explanation tests or if they should serve as an alternative to them. Schwartz and Lellouch1 made the distinction between explanation studies, which support a physiological hypothesis or clinical hypothesis, and pragmatic trials, that inform policy and practice decision-making. They also suggested a framework known as PRECIS for pragmatic trials.2 This tool tried to define the characteristics of a pragmatic study, including recruitment, design, delivery of the intervention and follow-up. There is an encouraging increase in the number pragmatic trials published. A recent Medline query using the keywords pragmatic and naturalistic, which was restricted to randomised controlled trials (RCTs), returned 34 articles. They are displayed in red on Figure 2. This suggests that the health sciences community has become more aware of the importance of pragmatic thinking. However, it is important to note that the majority of these studies were conducted in primary care settings.