ICU Doctors Tracked Their Own Urine for a Month and Fell Short of Their Critically Ill Patients

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Editorial Illustration via AI Share on Twitter Share on Facebook Share on Pocket Doctors in intensive care units spend their shifts tracking how much urine their patients produce, because a drop can be an early warning sign of kidney trouble. When a team in London applied the same measurement to the doctors themselves, the physicians came out looking worse than the critically ill people they were treating.

In a BMJ case-control study published on December 14, 2010, junior doctors at St George’s Hospital met the low urine output threshold on 22% of their shifts, compared with 15% of patient days. The doctors had about twice the odds of meeting it, and the study’s data monitoring committee stopped the research early “on safety grounds.”

The paper, titled “Urine output on an intensive care unit,” was written for the BMJ’s lighthearted Christmas issue. But later research suggests the problem behind the joke, health workers too busy to drink, is real.

The research team, led by Anthony Solomon and writing on behalf of the punningly named PARCHED investigators, ran the study over 22 consecutive weekdays from March 23 to April 23, 2009, in a 17-bed general ICU in southwest London.

Eighteen of 19 junior doctors volunteered. They emptied their bladders when they arrived for work, then measured every bathroom trip in a 1-liter graduated plastic jug and recorded the volumes. Patients’ output came from the unit’s routine hourly records between 8 a.m. and 8 p.m. Patients on kidney replacement therapy were excluded.

The researchers defined low urine output, known medically as oliguria, as an average below 0.5 milliliters per kilogram of body weight per hour over six or more hours. That cutoff comes from RIFLE, a standard framework for flagging people at risk of acute kidney injury.

Across 87 doctor shifts and 195 patient days, the doctors met the “at risk” level on 19 shifts, and one more shift reached the “injury” level, which in a patient would signal kidney damage. Patients were oliguric on 29 days. The odds ratio was 1.99, a statistically significant difference.

The doctors’ average output was 0.77 milliliters per kilogram per hour, not far above the warning line. Ten of the 18 doctors had at least one at-risk shift or worse.

The study had planned to collect 410 doctor shifts. According to the paper, the data monitoring committee stopped it early, and some authors were reaching the end of their ICU posting anyway.

The writing leaned into the joke. The authors reported that mortality among doctors was 0%, noted that the nursing staff had declined to monitor the doctors’ fluid balance, and concluded in the abstract: “We should drink more water.”

They also listed real limitations. They did not record how much fluid or caffeine the doctors consumed, could not rule out stress hormones lowering urine output, and acknowledged that being watched may have changed behavior. Doctors’ output was averaged over whole shifts, while patients were measured hourly.

Later studies suggest the BMJ finding was more than a holiday gag. A 2013 study in the International Journal of Emergency Medicine followed 22 physicians and 21 nurses in the emergency department of King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, across 172 shifts. Physicians lost an average of 0.57 kilograms during a shift, and lower fluid intake was a significant predictor of poorer hydration.

A larger U.K. study, known as HANDS on and published in Clinical Nutrition in 2016, followed 88 nurses and doctors at a Nottingham teaching hospital. Based on urine concentration, 36% were dehydrated at the start of a shift, rising to 45% by the end. Some 41% had low urine output over the shift, and dehydrated staff drank about 30% less fluid. Dehydration was also associated with poorer scores on a short-term memory test.

None of these studies proves that dehydrated clinicians make more mistakes. But they suggest that long shifts, short breaks, and limits on drinking in clinical areas can leave health workers short on fluids.

There is no single daily water target that fits everyone. The National Academies set reference intake levels of about 3.7 liters a day for men and 2.7 liters for women. Those figures cover total water, including water from food, not just plain drinking water. The same report said most healthy people meet their needs by letting thirst guide them.

The CDC notes that drinking water can prevent dehydration and help the body function normally. The challenge for health workers is that a busy shift can override thirst and make it hard to step away. Keeping water within reach and scheduling short breaks may help anyone working long shifts. People with heart or kidney conditions, or anyone told to limit fluids, should follow their own clinician’s guidance.

What did the BMJ urine output study find?

Junior ICU doctors met the low urine output threshold on 22% of shifts, compared with 15% of their patients’ days, giving them about twice the odds.

The paper says its data monitoring committee stopped it on safety grounds after the gap emerged, a largely humorous touch in a Christmas issue paper.

Does the study prove doctors are dangerously dehydrated?

No. It was small, did not track fluid intake, and compared shift averages for doctors with hourly readings for patients.

Have other studies found similar results?

Yes. A 2016 U.K. study found 45% of hospital doctors and nurses were dehydrated by the end of a shift, and a 2013 Saudi study found emergency physicians lost weight during shifts.

The National Academies set reference levels of about 3.7 liters a day for men and 2.7 liters for women from all drinks and food, and most healthy people can rely on thirst.