143 Discussion | 7 the working mechanisms of portfolio use could probably not unfold properly. Consequently, themetacognitive SRL constructs associatedwith portfolio use (e.g. reflection, monitoring) did hardly take place during portfolio use. In Chapter 5 a systems thinking methodology was used to explore possibilities to manage one of the two factors that declined motivation: tensions between portfolio purposes. The development of a polarity map® provided action steps to manage the tensions of multipurpose portfolio use. However, it became clear that these action steps require a high degree of commitment from all stakeholders involved, as exemplified by the importance of continuous conversations about portfolio use between stakeholders to create and maintain a shared frame of reference. It is questionable whether such a degree of commitment is attainable in the context of this thesis, as trainees and their supervisors are probably reluctant to invest this much time and energy in portfolio use when SRL is already achieved through their interaction. Moreover, the polarity that was identified in the fifth chapter – accountability and learner agency – is not unique to portfolio use, as it has also been described in concern to other aspects of current medical training programmes.19 As described in Chapter 1, current programmes are often based on competency based education (CBE). While CBE is theoretically intended to be flexible and learner-centred, the outcome-based nature of CBE can also be considered as a fixed and prescriptive image of how doctors should perform, think and act.19,20 Another important component of many medical training programmes is programmatic assessment (see Chapter 1 for further explanation). While single assessments are intended to support learning only, it has been reported that learners can also experience these assessments to be high-stake (i.e. resulting in pass/fail decisions), which is stressful for learners and can diminish learning opportunities.21 Consequently, doctors in training can experience pressure to continuously demonstrate that they are developing into the competent doctor that is prescribed by the medical training programme. Considering that the polarity between accountability and learner agency can be so fundamentally present in medical training programmes, one can wonder if it is possible to balance the polarity by means of portfolio use only. In order to adequately assess the merit of the conclusions described above, it is important to consider some concerns regarding portfolio research, as the studies of this thesis were built upon the results of previous studies that considered portfolio use for the support of SRL.
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