97 Focus group study | 4 Discussion We used focus groups to gain insight in the experiences of trainees, supervisors and faculty, to elucidate the functioning of portfolio use for the support of SRL. Respondents were doubtful about the learning benefits of portfolio use, as most trainees only used their portfolio to check off what was considered to be required. Nevertheless, some trainees did engage in SRL through portfolio use, as they actively formulated learning objectives and monitored their competency development. However, overall, our findings indicate that portfolio use did not support trainees’ SRL. Different stakeholder dynamics clarify this lack of support for SRL. It has been previously suggested that portfolio use is less useful when trainee and supervisor interact on a frequent basis.51 This aligns with our results: trainees felt obligated to document learning activities that would have taken place anyway, contrary to portfolio use facilitating a meaningful interaction between trainee and supervisor that could lead to SRL. In contrast, faculty, who are in contact with trainees on a less frequent basis, did interact with trainees by use of the portfolio. We argue that tensions between different portfolio purposes are an important factor explaining this interaction between trainees and faculty. Besides the purpose to support SRL, the portfolio also is an essential component of the assessment programme, and with that an important tool for accountability. Faculty members felt responsible for a fair and accurate assessment of trainees, and therefore directed trainees towards building comprehensive portfolios that fully cover the competencies developed during WPL. An unintended effect of faculty’s focus on ‘assessable’ portfolios was that ownership of the portfolio shifted from trainees towards faculty. As a result, trainees’ experienced little leeway to use their portfolios for the sake of SRL. Moreover, these tensions between portfolio purposes can also explain the ambiguities that were identified in concern to portfolio use. While the importance of clear guidelines during portfolio use is well known,24,52 in practice the instructions provided to trainees varied as different stakeholders focused on different purposes. We are not the first to find that assessment and/or accountability can overshadow SRL, thereby adding to the debate on the (un)desirability of multipurpose portfolios.23,24,53,54 Going into this debate it is important to realise that above-described tensions extend beyond portfolio use. Instead they signify a discrepancy within our educational system: while explicitly communicating the aim to foster agency in learners, our system implicitly urges learners to conform to external expectations.55-58 Agency refers to ‘one’s capacity to act purposefully andautonomously’ and is considered intrinsically valuable during education, as also shows in in our efforts to support SRL.56(p1) However, at the same time current curricula are outcome-based and communicate a clear image of how a doctor (in training) should perform, think and act.55 Consequently, our appreciation of learner agency is often only theoretical, as education comes with accountability which is best served by fixed measures and outcomes.
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