We read with great interest the article by Brandt et al on the 100 most frequently cited papers in obstetrics and gynecology journals during the last 50 years. Surprisingly, only 7 RCTs were included, whereas the rational increase in influential RCTs percentage after 1980 was rather disappointing. As the authors admit, the exclusion of articles published in general medicine and surgery journals may have underestimated the reported impact of obstetrics and gynecology related RCTs. Moreover, the poor quality of the reporting RCTs conducted before mid 1990s may have undermined their use as references. However, these findings should launch an indepth debate: are we still in lack of high-quality evidence driving the fundamental aspects of our clinical practice?

Apart from ethical issues–occasionally, one major problem of RCTs, especially in perinatal medicine, hides in the recruitment of the targeted sample size, resulting in either underpowered or time-consuming and costly studies. Barriers pertaining to the patient, the health provider, the institution involved, and the study design usually take the blame for that. In contrast, as Vintzileos heretically states “in obstetrics, the best evidence should not be restricted to RCTs, because it could be found in real-life observational studies”; based on specific examples, his personal perspective emphasizes the problem and merits special consideration.

Evidence-based medicine incorporates the physician’s experience, the current best of knowledge and the needs of an individual patient. Until robust evidence fails to prove the improvement of patient care because of the RCTs conclusions-guided clinical practice, if ever, RCTs should be considered as the best tool to judge the effectiveness of a medical intervention. In this context, obstetrics and gynecology leaders should leave no stone unturned in their effort to promote RCTs implementation. Assessing different/suitable recruitment strategies may optimize the patients’ enrollment. The worldwide introduction–and function–of “the basic principles of research methodology” even in medical students’ curriculum may help them better evaluate the scientific value of published articles and cautiously choose those they should rely on in the future. Finally, changing the journals policy regarding the references of each submitted paper might be an additional option: why should the authors prefer citing exclusively an observational study when an RCT with inherently better level of evidence on the same topic exists? It is probably time to offer further acknowledgement to research pioneers and a strong incentive to all others.