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They are also a good way to identify the cause-effect relationship between the intervention and its effects. However, they should not be used to substitute for the use of explanation studies. The concept of pragmatism is controversial, and there are questions regarding whether pragmatic trials could be used to replace explanation tests or if they are an alternative to them. Schwartz and Lellouch1 suggested the distinction between explanation trials, which validate the clinical or physiological hypothesis as well as pragmatic trials, which inform the practice and policy decisions. They also suggested an approach to pragmatic trials, which they called PRECIS.2 This tool sought to define the elements of a pragmatic trial that include recruitment, design and delivery of the intervention, as well as follow-up. The number of pragmatic trials is growing. A recent Medline search using the words naturalistic and pragmatic, restricted to randomised controlled trials (RCTs), returned 34 articles. They are displayed in red on Figure 2. This indicates that the health sciences community has become more aware of the importance of pragmatic thinking. It is important to remember, however, that the majority of these studies were conducted in primary care settings.