Thank you for the opportunity to review this paper. The authors assess the changes in diagnosis of fibrotic ILDs after MDD compared with the treating physician's primary diagnosis. They also analyze the MDD effect on additional investigations made and treatments. The study is very interesting, focusing on an important topic which is vital to the diagnostic evaluation of almost any patient with ILD. After reading the paper, some issues should be addressed.
1. The most important issue is that the authors must clarify on the timing of the MDD diagnosis they refer to in their analysis. For example, if a patient saw a physician after having a CT scan and the physician gave a primary diagnosis of IPF. Then, the MDD was not sure of the diagnosis and sent the patient for a trans-bronchial biopsy and additional serological tests, which yielded a diagnosis of anti-synthetase syndrome. What would be the diagnosis of the MDD? I think it should not be anti-synthetase. Obviously, once additional testing is made, such as biopsy, the final diagnosis will often change, even without the MDD. Therefore, this example does not represent a real difference in the diagnosis between the treating physician and the MDD, but rather a change in the evaluation needed. Only when using similar baseline data, you could really estimate the difference between pre and post MDD diagnosis.
This issue is also true for change in management. Obviously, if the primary diagnosis was IPF, and then anti-JO came back positive (after the MDD decided to order it), management would have been changed by the treating physician and the MDD, although the patient already had the MDD. How do you address these cases? Are the treatments given by the referring physicians being assessed after the final evaluation?
2. More details on the evaluation process in your institution should be given (which investigations are made before MDD? What includes the basic serological testing? and so on). This should include the timing for an MDD in this process. For example, in our institution, every ILD case must be brought up in an MDD before a decision on biopsy is made. Does that mean all biopsies are made only because of the MDD in our institution? not really, as most patients would have been sent for a biopsy by their treating physicians.
3. Did referring physicians were experts in ILDs?
4. Did patients signed informed consent considering that this was a prospective study?
5. Given that this is a prospective study; it would be of interest to know which investigations changed the final diagnosis by the MDD. It could be interesting to know if procedures like BAL had any effect on final diagnosis.
6. Which diagnostic confidence did you count for a final MDD diagnosis? You specified the different Ryerson categories in the methods, yet you did not classify the MDD diagnoses by these levels in the results.
7. I think that the most striking finding is the very high rate of false IPF diagnoses, which aligns with prior studies. The authors should give some ideas on how to minimize this gap, especially as MDD is not readily available in many small or rural centers. For example, referring patients to rheumatologists for further investigations and performing routine serological analysis. Another example is to use a standardize questionnaire to assess for exposures, which could be of great value. A large study found that using the CHEST ILD questionnaire led to significantly higher rate of relevant exposure identification (DOI: 10.1186/s12890-022-02294-3). This example and other should be used.

Thank you for the opportunity to review this paper once again. I also want to thank the authors for their in-depth and respectful answers to each of my comments. The article has significantly improved.
The only remaining issue is that I could not find where the authors mention if patients signed informed consent. This is obviously crucial and is a basic step for any prospective study. Please explain.
Thank you and good luck.