141 Discussion | 7 Medical training programmes across the world have implemented portfolios.1 In many cases these portfolios are (also) intended to support self-regulated learning (SRL) of learners, as SRL is associated with effective learning during education and lifelong learning after graduation.1-3 However, since portfolio research within the field of clinical workplace learning (WPL) has mainly focused on other purposes of portfolio use (e.g. assessment), it was unclear to what extent, in which ways and under what circumstances portfolio use actually supports SRL during clinical WPL.4,5 Therefore, this thesis was conducted to answer the following central research question: How does portfolio use affect SRL during clinical WPL? In this chapter, the main conclusions concerning this research question will be discussed by use of the findings of this thesis and the extended research literature. Subsequently, these main conclusions will be put into perspective by discussing various concerns regarding portfolio research. This thesis will be concluded by outlining strengths and limitations, implications for practice and further research. Main conclusions As a first step in answering the research question, a realist review was performed (Chapter 2). Through extraction of context-mechanism-outcomes configurations from the included research papers, two working mechanisms of portfolio use for the support of SRL were specified: documenting as a moment of contemplation (learners analyse experiences while writing portfolio reports) and documentation as a reminder of past events (learners are reminded of past experiences when reading previously documented portfolio reports). The included papers indicated a relationship between these working mechanisms and reflection, self-assessment, and exchange of feedback. Less evidence was found for the contribution of portfolio use to other SRL constructs that are often associated with portfolio use: formulation of learning objectives and plans, and monitoring. Moreover, the papers did not discuss relationships between different SRL constructs, so it was unclear whether portfolio use actually promoted learning cycles over time. Finally, the realist review showed that contextual factors (e.g. pressures of clinical WPL) and factors related to portfolio use (e.g. how the portfolio was used during mentoring) could easily disrupt the working mechanisms of portfolio use, and with that SRL. This might explain the disappointing results of various studies that evaluated the use of portfolios for the support of SRL.6-12 An important factor related to disruptions of portfolio use for the support of SRL was discussed in multiple studies of this thesis: tensions between different portfolio purposes (Chapter 2, 4, 5). Previous publications on portfolio use, had already reported that portfolio assessment can interfere with the support of SRL.5,13,14 In accordance, the system of assessment was included in the realist review as an important contextual factor that could
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