To the Editor The article by Dr Bellani and colleagues1 did not describe the role of the clinicians treating patientswithARDS in the study, in particularwhether they knew if their skills diagnosingARDSwere being tested. This is relevant to a conclusion drawn by authors in the discussion section. If clinicians were aware of the study purpose (based on the fact that they were asked aboutARDSat 2 separate times in the study), then the conclusion that ARDS might have been underrecognized in the studymay not be correct. If physicians were conscious ofbeingevaluated for theirdiagnostic skills, theywouldbe less likely to miss the diagnosis and instead would overdiagnose it. Thus, clinician recognitionofARDS in the studymighthave occurredmore frequently than it would in real-world clinical practice.