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They are also a good method of determining the cause-effect relationship between an intervention and its outcomes. They should not, however be used to replace the need for explanation studies. The concept of pragmatism is controversial and there are doubts about whether pragmatic trials should be used to replace explanation tests or if they should be a complement to them. Schwartz and Lellouch1 suggested the distinction between explanation trials, which validate a physiological or clinical hypothesis and pragmatic trials, which guide policy and practice decisions. They also proposed a framework called PRECIS for pragmatic trials.2 This tool attempted to define the traits of a pragmatic study, including the recruitment, design, and delivery of the intervention, and follow-up. The number of pragmatic trials is growing. A recent Medline query that used the words naturalistic and pragmatic, restricted to randomised controlled trials (RCTs), returned 34 articles. These are highlighted in red on Figure 2. This suggests that the health sciences community is becoming more aware of the importance of pragmatism. However, it is important to keep in mind that the majority of these trials were conducted in primary care settings.