71 Content analysis | 3 learning process.12 Common educational practice, such as the assessment of reflections and learning goals and the use of portfolio content as starting point for supervision (meetings), are based on these assumptions. Our study shows, however, that the documentation of these SRL processes – reflection, feedback, goal-setting and planning, and monitoring – is limited within the portfolios of GP trainees. Previous studies have explained that (mandatory) written reflections have certain predicaments, that can potentially reduce reflection into a ‘tick-box-exercise’ which shows through documentation of shallow reflections.53-56 An example of such a predicament is the apprehension that can be felt towards written reflections, i.e. the documentation of vulnerabilities, as such documentation might be considered harmful for assessment, professional development or legal issues.50,56,57 Furthermore, our results concerning feedback are not uncommon, as the review of Bing-You et al. shows that more than a quarter of the 51 included articles on feedback exchange reported problems with low quality feedback, due to limited information, lack of specificity and absence of action plans.58 With regard to goal-setting and planning previous studies have shown that learners hardly ever integrate goals into their WPL, unless they receive tailored coaching focused on effective goal-setting.59-62 Although, the importance of monitoring of learning is often mentioned, there is still limited evidence of monitoring behaviour within medical education.45 Considering the near absence of the included SRL processes in the portfolio content, could result in the simple explanation that trainees do not engage in SRL. However, a previous study using interviews, also targeting Dutch GP trainees, indicated that trainees did purposively regulate their learning.63 The occurrence of SRL related cognitions, motivations and behaviour of trainees that probably took place - whether or not instigated by the portfolio - is apparently not captured in portfolio forms or content. This could be explained by a variety of factors of some have been described above. In addition, trainees might not find the right words to accurately describe the SRL processes taking place. As SRL processes are complex, and might (partly) take place on a subconscious level,64 formulating if and how they were present asks for a high level of introspection and writing skills. Difficulties to adequately document the presence of SRL processes in a portfolio might be fuelled by another factor that is part of WPL: a need to prioritise. When working in the clinical setting, where time pressure and a certain level of unpredictability are inevitable,14,16,65 trainees might not experience the time required to appropriately document the learning processes taking place. However, SRL processes may still occur in the head of trainees or be a topic of discussion with supervisors and teachers. Another factor explaining the limited documentation of the different SRL processes might concern the difficulties that can occur when combining multiple purposes – assessment, accountability and support for SRL – in one portfolio.66 The way the current GP portfolio was implemented might also have contributed. During implementation the focus was on assuring an appropriate functioning of the portfolio, especially regarding
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