Being a physician involves using up-to-date knowledge to deliver the best possible care to patients [1, 2]. An important aim of health care is to avoid a so-called care gap: a discrepancy between the processes of care defined as best practice on the basis of high-quality evidence and the health care provided in usual clinical practice . Evidence-Based Medicine (EBM) has been developed as a strategy to meet this challenge and to apply scientific evidence to the medical practice. EBM is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients . Unlike hospital clinicians and general practitioners, occupational physicians have the special responsibility to take into account the working conditions of their patients, opportunities and priorities for management, and the impact of legislation in the field of occupational health and safety . As occupational physicians need knowledge from many different sources and disciplines, EBM can be a useful strategy for them . However, persistent barriers in the implementation of EBM for both clinicians and occupational physicians remain . Physicians report a lack of time to practice EBM, they face an ever-growing quantity of scientific evidence that is not easily accessible, and especially older physicians find it hard to acquire EBM skills [7–9].
Knowledge management is currently making its entrance into the medical world and can reinforce the EBM practice of physicians. Knowledge management is a planned approach to collecting, evaluating, integrating, sharing, and improving knowledge, and generating value from it. In the occupational health field, knowledge management can provide an effective and efficient way of organizing what is known and, by using this, improve the quality of occupational health care. Although technology has improved the ability to collect, analyze, and share knowledge rapidly, it has also produced fragmentation of information and systems that are not well integrated. This challenges practitioners' ability to use existing knowledge to advance occupational health practices. Therefore, knowledge management needs to be supported by a knowledge infrastructure so that the right information can be delivered to the right person and place at the right time [10–12]. A knowledge infrastructure includes organizations and institutions in the public – and sometimes also private – sector whose role is the production, maintenance, distribution, and protection of knowledge, e.g. research councils, institutions of higher education, libraries, databases, legal and administrative regulations to support the well-functioning of these entities.
Grimshaw (2004) distinguishes potential push, pull, and linkage and exchange components for an effective knowledge infrastructure. Examples of push components are: help, advice, and information services, practice guidelines, clearing houses for evidence-based tools and knowledge sharing networks. Training in critical appraisal can be seen as a pull component. Local research and development initiatives to identify research priorities and to support local quality improvements can be seen as a linkage and exchange component .
As occupational physicians need knowledge from many sources and disciplines to practice EBM, they may benefit from a well-organized knowledge infrastructure to successfully gain access to the required knowledge. Expanding on the findings of Grimshaw (2004), we tried to distinguish elements in the knowledge infrastructure for occupational health. These elements can be regarded as clusters of key facilities that need to be available and that have to be of good quality to support practice. We distinguished four specific elements: (1) education and training, (2) research and development, (3) knowledge products and tools, and (4) knowledge dissemination and access facilities .
Elaborating on these four elements, and starting with the first, education and training facilities include basic professional training and continuous professional education, which should be based on the latest body of evidence based on good quality research. One aspect is training in EBM strategies which are necessary to guarantee the use of up-to-date evidence in occupational health care. Research and development include research activities on occupational health and safety by national and regional scientific institutes, universities, professional associations, and private research and development organizations. These activities lead to the production of new knowledge, knowledge products, and tools that can contribute to the evaluation and innovation of health practices. Subsequently, there is a need for custom-made knowledge products conceived as purposefully developed prescriptions or recommendations for practice. Examples of these are: threshold limit values, practice guidelines, protocols for measurement and for evaluation. These products combine scientific evidence with e.g. practical experiences, and often also with legal, economical, ethical, and cultural constraints. They can be interpreted as forms of translation of specific research evidence into practice with the aim of being more directly applicable. Finally, concrete storage, access, and dissemination facilities for knowledge and knowledge products are needed that can be found in (digital) libraries, literature databases, clearing houses, high-quality evidence-based websites, journals, and helpdesks for professionals.
Knowledge infrastructure facilities can be arranged on the local, national and international levels. Locally, a technical infrastructure is needed, such as internet access at the workplace in a company or occupational health service. On a national level, ministries of Labour and of Health Care, national institutes for occupational health and safety, occupational or public health departments at universities, and professional organizations, are key actors. On the international level, key institutions can be identified such as the International Commission on Occupational Health (ICOH), the World Health Organization (WHO), the International Labour Organization (ILO), and the Occupational Health Field in the Cochrane collaboration.
The presence and quality of a knowledge infrastructure is thought to affect the practice of EBM in occupational health care. However, to set priorities and to define concrete objectives for improvement, we need to know more about the impact of the presence and importance of various knowledge infrastructure facilities for EBM practice. Therefore our research question is: "Which contemporaneous evidence-based information do occupational physicians access to guide their evidence-based practice, and what are the enablers and barriers to them practising EBM?" Subsequently, in this study we explore the knowledge infrastructure in an international approach as we perceive many advantages in the development of an international perspective and in new initiatives fostering international collaboration. The study aims to explore what facilities in the knowledge infrastructure are used and are perceived as important by occupational physicians who are enrolled on EBM training courses in different countries in their EBM practice. Secondly, it aims to explore which (evidence-based) sources OPs use to solve their cases. Finally, the study aims to inventorise the enablers and barriers that OPs experience when practising EBM.