The panel of participants was composed of specialists in family medicine with an interest in respiratory diseases, who are part of the Respiratory Diseases Interest Group (GRESP) of the Portuguese Association of General and Family Medicine (APMGF). Additionally, specialists in family medicine with responsibilities in pre and post-graduate education, trainees who are members of GRESP and specialists in pulmonology and immuno-allergology were also invited.

A total of 71 experts were invited to participate, of whom 43 were male (60.6%) and 28 were female (39.3%). The participants were from several districts in Portugal, including 42 from the north (59.2%), 26 from the central zone (36.6%) and 3 from the south (4.2%). Regarding medical specialties, 58 (81.7%) were specialists in family medicine, 9 (12.7%) were from pulmonology, and 4 (5.6%) were from immuno-allergology. Regarding teaching roles, 30 (42.3%) were university teachers and 26 (36.6%) were vocational training supervisors. Table 1 shows the characteristics of the participants by gender, specialty, and geographical area, and their participation in rounds 1 and 2.

The Learning Curriculum Framework was based on the Respiratory Medicine Advanced Training Curriculum from the Royal Australasian College of Physicians.19 The final version consisted of 399 items, divided into 16 themes related to respiratory diseases. Each topic was subdivided into sections relating to knowledge, expertise, and skills. The topics included in the document were: the structure and function of the respiratory system, presenting problems, diagnosis, interventions and prevention, asthma, COPD and emphysema, tumours, pulmonary infections, tuberculosis, pulmonary manifestations of HIV-AIDS, thromboembolic and vascular disease, pleural disease, pregnancy and respiratory diseases, respiratory sleep disorders, iatrogenic respiratory diseases, and respiratory research.

The Australasian document was readily available, comprehensive and robust. It has proven its worth in practice in the setting in which it was constructed.19 It provided a convenient starting point for this study without the need to start the process from a blank canvas. The positive response to this format from the Delphi experts in this study seems to support this choice.

The original Australian document was translated from English to Portuguese and adapted by the research team, and the translation was cross-checked. The resulting document was reviewed in order to eliminate items corresponding to knowledge and skills that did not fall within the scope of family medicine. Its final wording was defined by consensus by the team. A pilot test was conducted with 7 individuals. The objective was to detect errors such as items not suitable for family medicine, repetition of items, misspellings, and errors in translation.

The study was carried out between September and November 2017 and was conducted via electronic mail, using Google Drive.½ folders and an Excel.½ spread sheet. The statistical analysis was done on an anonymised database.20 The study consisted of two rounds of questionnaires sent to the participants. Participants had access to the results of the first round before participating in the second round.16 Communication with the participants was done through an e-mail account created for this purpose. All messages sent, as well as collected data, were reviewed by researchers to ensure clarity, simplicity and functionality of the entire process. An e-mail was sent to all potential participants, containing a brief description of the study and its objectives, inviting them to collaborate. After agreeing to participate, a code number was assigned to participants, to ensure anonymity.

In the first round, participants were asked to assess the importance of items for inclusion in the family medicine training curriculum on a five-point Likert-type scale (from 1=not important to 5=very important). The mean group responses for each item were calculated. A cut-off of 80% was chosen as the agreement value for scores of 4 and 5. Participants were asked to compare their responses from the first round to the group average and to re-assess the items. The objective was to promote reflection by the participants in order to reach consensus. At the end of the second round, the results were analyzed and the cut-off applied for consensus. Consensus was considered to have been obtained in all items that had a concordance of at least 80% for the scores of 4 or 5, on a scale of 1...5.

In the first round, 3.6% of the items were considered irrelevant. All the items were included in the second round.

Of the 399 items in the document, 159 (38.8%) reached a level of agreement of at least 80%, with a classification of 4 or 5, on a scale of 1...5. The distribution of the items by themes was as follows : respiratory system structure and function (0.6%), presenting problems (21.4%), diagnosis (7.5%), interventions and prevention (15.7%), asthma and emphysema (12.6%), tumours (3.1%), pulmonary injuries (10.7%), tuberculosis (5.7%), pulmonary manifestations of HIV-AIDS (1.3%), thromboembolic and vascular disease (2.5%), pleural disease (3.1%), pregnancy and respiratory diseases (0.6%) and respiratory sleep disorders (3.8%). Iatrogenic respiratory diseases and respiratory clinical research did not reach consensus for any of their items. For lung manifestations of HIV-AIDS and, and respiratory disease in pregnancy, only one item had sufficient agreement. The complete analysis of all the items studied, including response averages and cut-off percentiles are available as a Supplementary file.

Table 2 lists all the items evaluated initially, as well as those that obtained consensus, distributed by themes. The averages of the responses in rounds 1 and 2 are presented for information only and did not serve as a basis for decision-making on items that met consensus. This decision was made based on the criteria described above. The proposed curriculum is available as a Supplementary file.

This study was designed to develop a national consensus on the knowledge and skills that family physicians must acquire in respiratory diseases by the end of vocational training. Broader subjects such as the importance of multi-morbidity and polypharmacy, or the importance of psychosocial factors in respiratory diseases, are already an important part of vocational training in family medicine in Portugal.21...23

Using the Delphi method, 159 items (38.8% of the original 399 items) grouped in 14 themes, were identified by consensus of a panel of experts. Half of the total number of items included in the curriculum belonged to the themes ..úpresenting problems..., ..úinterventions and prevention... and ..úasthma and emphysema... (12.6%).

The European Academy of Teachers in General Practice/Family Medicine (EURACT), through its Educational Agenda,24 proposes a reference tool for the various teaching and training programs of family medicine at European level. In addition to defining core competencies for a family physician, it also proposes the best teaching strategies and how and where they should be taught. In addition to describing learning objectives in primary health care management, it encompasses the competencies required for a patient-centred, holistic, comprehensive and community-oriented approach. However, this document does not focus specifically on the knowledge and skills of each group of diseases.

The Portuguese training portfolio in family medicine25 is a support tool for guidance and evaluation of trainees in family medicine. It is organized by knowledge, attitudes, and skills and is assumed to be a dynamic and evolving document, adaptable to the needs of the specialty and sensitive to the contributions of all who are involved in it. It addresses the core competences of family medicine. For RD, learning objectives for knowledge, attitudes and skills are generally well established. However, the document does not specify, for each disease, what is essential to know. In addition, it is not used homogeneously throughout the country. In other European countries, the reality is similar.26,27 Learning curricula are divided into two major areas, one of which is composed of core or core competencies, and the other is dedicated to the competencies of clinical areas. The Spanish26 and English.27 experiences are worth noting. The Spanish portfolio is similar to the Portuguese portfolio. It lists objectives, but does not explore the components of each of them. One of the objectives is that the trainee must ..úknow how to carry out the approach to smoking cessation...,26 however, it does not state the skills that are required in order to implement smoking cessation. The Portuguese portfolio requires the trainee to attend at least 5 smoking cessation consultations with a tutor and then to conduct one independently. The present study included 11 items on smoking and smoking cessation (5 of specialized knowledge and 6 of competences) and all of them reached a high degree of agreement. Objectives require defined knowledge and skills with greater specificity. In the United Kingdom, the objectives are organized into 12 core competencies consisting of different items depending on the clinical module in question.28 For respiratory health, emphasis is placed on disease management including interpretation of data from the clinical history, physical examination and pulmonary function tests, leading to correct diagnosis and proper treatment. It emphasizes the effect that the personal experiences of the physician can have on patients... approach, as well as communication, ethical aspects, and teamwork within a health system. The objectives are presented in a detailed way, specifying some competences, but not stating the desired level of detail.

The present study identified the specific knowledge and skills to be acquired and that are omitted from other national portfolios. For asthma there was a high degree of agreement regarding certain competences such as developing management plans and writing written action plans for the patient. All the competences related to the diagnosis, treatment and education of the patient were also considered important. There was consensus on the importance of ordering, and interpretation of diagnostic tests (e.g. spirometry or cutaneous allergic tests) though it was not considered important for the family doctor to conduct these tests alone. This is consistent with the current training portfolio.

This study also identified conditions not mentioned in the portfolio such as the pulmonary manifestations of HIV/AIDS, thromboembolic disease, and sleep disorders. There was no consensus on the importance of items related to respiratory clinical research. However, the ability to critically interpret research on respiratory diseases was close to reaching consensus. Teaching research skills during training in family medicine is an idea that is gaining popularity in many countries in Europe.29 Iatrogenic respiratory disease also did not reach consensus on any of its items.

No analysis was made of the reasons participants included or excluded items. However, a reflection on the excluded set of items suggests that knowledge and skills learned during basic medical education (e.g. anatomy and physiology, RD in pregnancy, thoracic tumours and their differential diagnosis, staging, treatment and prognosis) do not need to be included in vocational training. The competences of other health professionals, such as nurses or cardio-respiratory technicians (e.g. conducting tests and examinations like spirometry) may also have been excluded. Further study is needed to clarify this.