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Schwartz and Lellouch1 made an distinction between explanation-based studies, which confirm the physiological hypothesis or clinical hypothesis, and pragmatic trials, which inform policy and practice decision-making. They also suggested a framework dubbed PRECIS for pragmatic trials.2 This tool attempted to define the elements of a practical study that includes recruitment, design, delivery of the intervention and follow-up. The number of pragmatic trials is increasing. A recent Medline search using the words pragmatic and naturalistic, limited to randomised controlled trials (RCTs), returned 34 articles. These are shown in red on Figure 2. This suggests that the health sciences community has become more aware of the importance of pragmatic thinking. It is important to keep in mind that the majority of these studies were conducted in primary care settings.