Chinese medical students’ perceptions of gout: a pilot study

Abstract

Background

Gout is the most common inflammatory arthritis worldwide, but doctors have a relatively poor understanding of gout that affects optimal management. There is only limited knowledge about medical students’ understanding of gout. Therefore, the aim of this study was to investigate medical students’ perceptions of gout and hyperuricemia.

Methods

This was a cross-sectional, questionnaire-based study conducted in June 2022 among Chinese medical students, primarily from four colleges in different geographic regions. Participants were asked to complete a 27-question survey on demographics, gout-related perception questions (derived from previous surveys), and attitudes toward gout and its management. Knowledge and perceptions of gout and associated factors were analyzed.

Results

The median score on the 11 gout-related perception questions was 8.0 (interquartile range 6.0–8.0). Medical students showed a relatively high accuracy in identifying the relationship between gout and hyperuricemia, as well as the clinical manifestations of gout. However, their performance varied in questions related to gout management and was notably poor in areas concerning urate-lowering therapy and drug-induced hyperuricemia. Students with clinical exposure, interest in gout-related specialties, or prior interaction with patients with gout or hyperuricemia demonstrated higher perception scores. Additionally, the source of information significantly influenced students’ understanding of gout.

Conclusions

Chinese medical students exhibit insufficient understanding of gout and hyperuricemia. Future initiatives to improve gout education should prioritize instruction on urate-lowering therapy and guide students to actively consult clinical guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07886-1.

Background

Gout is the most common inflammatory arthritis, with a global prevalence of approximately 1–6.8% and an incidence of 0.6 to 2.9 per 1,000 person-years, resulting in a significant disease burden worldwide [1]. Even though gout is a curable disease that can be effectively managed through continuous and regular urate-lowering therapy (ULT), its management remains suboptimal, with only 47% overall adherence to ULT [2]. The situation is particularly concerning in China, where there were 16.2 million cases in 2019. The age-standardized prevalence rate exceeded the global average [3], and adherence to ULT was only between 9.6% and 21.9% [4, 5]. Suboptimal management of gout and hyperuricemia can lead to painful and incapacitating inflammatory arthritis flares and increase cardiovascular events and related mortality risk [6, 7], leading to substantial economic burdens for both individuals and the healthcare system [8].

Physicians serve as a primary source of health-related information for patients [9]. However, inadequate physician knowledge regarding the diagnosis, long-term complications, and treat-to-target care in gout has been shown to impair patient education [10, 11]. Consequently, patients often harbor misconceptions about gout, which can result in unfavorable attitudes and less proactive management behaviors [11]. As future healthcare providers, medical students must receive sufficient education in gout management; otherwise, they will be ill-equipped to convey accurate and helpful information to patients during clinical practice. Even in diseases emphasized in medical curricula—such as diabetes—medical students have been shown to perform poorly in knowledge assessments [12]. Given that gout and hyperuricemia receive relatively limited attention in medical education, concerns about knowledge gaps among medical students are well-founded.

Therefore, this study sought to pilot an assessment of Chinese medical students’ perception of gout and hyperuricemia, with the goal of informing future comprehensive investigations and guide targeted improvements in medical education on these conditions.

Methods

This was a cross-sectional, questionnaire-based study of medical students’ perception of gout and hyperuricemia conducted in June 2022. An online questionnaire was distributed using a snowball sampling method on the Wenjuanxing platform (https://www.wjx.cn/). To ensure a representative sample from various parts of the country, we selected students from four medical schools based on their geographic locations as “seeds”. Then, they recruited additional respondents from their social networks. Two medical schools were located in southern China (Changsha and Shanghai), while the other two were located in northern China (Beijing and Harbin).

The questionnaire consisted of three sections: (i) eight items about general information, such as gender, medical school, year of study, preferred medical specialty, and sources of information on gout; (ii) 11 items to evaluate gout-related perceptions including questions about the relationship between gout and hyperuricemia (2 items), clinical manifestations (1 item), treatment of gout flares (2 items), management of chronic gout (4 items), comorbidities of gout (1 item), and drugs that elevate serum urate levels (1 item); and (iii) eight items to assess self-reported familiarity, severity, and management status of gout and hyperuricemia.

Section (ii) was constructed based on a prior questionnaire survey [13]. The 10-item questionnaire, developed in both Chinese and English, exhibits moderate internal consistency for most questions, with intraclass correlation coefficients for individual questions ranging from 0.29 to 0.81. Although originally developed for use among patients, the questionnaire has been applied to evaluate gout-related knowledge among clinicians from various levels [14–18], as well as among nurses [19]. Two experts involved in developing Chinese guidelines for gout and hyperuricemia and instructing relevant courses at Peking Union Medical College evaluated the questionnaire. One question was disregarded due to unsuitability for the student population, while two novel questions, inspired by a questionnaire utilized among Croatian medical students [20], were incorporated. To further ensure the appropriateness of the questionnaire, a pilot test was conducted among a purposive sample of medical students, including ten pre-clinical and ten clinical students. All the feedback during the process was considered when revising the questionnaire. Full details of the questions are available in the Appendix. Section (iii) consisted of eight items, including five questions employing a 5-point Likert scale (from fully disagree to fully agree) to assess students’ self-reported familiarity with the diagnosis and management of gout and hyperuricemia, perceptions of disease severity for these conditions, and evaluations of the healthcare system’s effectiveness in managing them, along with two single-choice questions to allowing students to self-assess their understanding of first-line ULTs and alternative agents, and a ranking question designed for the relative familiarity with four clinical entities (gout, hyperuricemia, hypertension, and rheumatoid arthritis).

Data were analyzed using SPSS statistical software (v26.0; IBM Corp, Armonk, NY). Variables are presented as whole numbers and percentages, and total scores for gout-related perceptions are presented as medians and interquartile ranges (IQR). Comparisons were made using the Mann-Whitney U test and Kruskal-Wallis test for two or more than two groups, respectively. Associations between students’ demographic information and perception scores were assessed using the chi-squared test and linear regression. The adopted significance level was 5%.

All participants were informed that their responses would be confidential and anonymous. Additionally, the ethical review committee of Peking Union Medical College Hospital exempted this study from ethics approval due to the use of anonymized materials.

Results

The basic information collected from participants is summarized in Table 1. Three hundred and sixty-three geographically diverse participants from 29 medical schools completed the survey. Students mainly attended four medical schools. Of these, 212/363 (58.4%) were female, 68/363 (18.7%) were in pre-clinical training, and 295/363 (81.3%) had been exposed to clinical practice. 255/363 (70.2%) participants had been exposed to gout or hyperuricemia patients. 126/363 (34.7%), 114/363 (31.4%), and 123/363 (33.9%) participants selected internal medicine, surgery, and other departments as their career choice, respectively. More specifically, 88/363 (24.2%) participants preferred specialties that were more likely to deal with gout, including rheumatology, endocrinology, nephrology, cardiology, and orthopedic surgery.

Table 1.

Basic information for participants

Characteristics		N (%)
Gender	Males	151/363 (41.60)
	Females	212/363 (58.40)
School	Peking Union Medical College, Beijing	74/363 (20.39)
	XiangYa School of Medicine, Changsha	60/363 (16.53)
	Harbin Medical University, Harbin	74/363 (20.39)
	Shanghai Jiao Tong University School of Medicine, Shanghai	92/363 (25.34)
	Others	63/363 (17.36)
Period of medical school	Pre-clinical stage	68/363 (18.73)
	Clinical stage	295/363 (81.27)
Specialty preference	Gout-associated specialtiesa	88/363 (24.24)
	Others	275/363 (72.76)
Exposure to gout patients	Yes	255/363 (70.25)
	No	108/363 (29.75)

^aGout-associated specialties include rheumatology, endocrinology, nephrology, cardiology, and orthopedic surgery

The response of Chinese medical students to various questions about gout and hyperuricemia is given in Table 2. The median score for the 11 questions was 8.0 (IQR: 6.0–8.0). Participants were generally correct in their answers about the relationship between gout and hyperuricemia (264/363, 72.7%) and clinical manifestation of gout (296/363, 81.5%). However, answers on its management varied. 141/363 (38.8%) and 36/363 (9.9%) identified all the correct answers for gout flare and chronic gout management, respectively. 319/363 (87.9%) knew the common comorbidities of gout. On individual items, 168/363 (46.3%) correctly responded that ULT should be withheld while non-steroidal anti-inflammatory drugs or colchicine should be added if there is an acute attack when initiating ULT. 95/363 (26.2%) and 145/363 (39.9%) participants correctly identified the ideal serum uric acid (SUA) level after treatment and appropriate duration of ULT, respectively. Only 11/363 (3.0%) identified all the common drugs that increase serum urate levels, while 40.8% selected “not sure” without choosing any specific drug. It is worth noting that the final item was the only question in the questionnaire that allowed multiple answers.

Table 2.

Questions on gout-related knowledge

Statement	Perception, n (%)
Relationship between gout and hyperuricemia	264 (72.72)
Q1. Pathogenesis of gout	362 (99.72)
Q2. Relationship of hyperuricemia and gout	265 (73.00)
Clinical manifestation
Q3. Typical clinical manifestation of gout flares	296 (81.54)
Treatment during gout flare	141 (38.84)
Q4. Drugs for treating gout flares	278 (76.58)
Q5. Treatment when initiating ULTa	168 (46.28)
Management of chronic gout	36 (9.92)
Q6. Drugs for lowering SUAb	251 (69.14)
Q7. Target SUAb levels	95 (26.17)
Q8. Duration of ULTa	145 (39.94)
Q9. Non-pharmacological interventions for lowering SUAb	322 (88.71)
Comorbidities of gout
Q10. Complications of gout	319 (87.87)
Drugs elevating serum urate level
Q11. Drugs that elevate SUAb levels	11 (3.03)

^a ULT urate-lowering therapy, ^b SUA serum uric acid

Students’ perceptions of gout and hyperuricemia differed significantly by clinical experience, intended specialty, institution, and prior patient exposure; however, no significant differences were observed by gender. Participants who had experienced clinical practice (8.0, IRQ 6.0–9.0) scored higher than those in the pre-clinical years (6.0, IRQ 5.0–8.0, p < 0.001). As expected, there was an association between clinical practice and clinical exposure to gout/hyperuricemia patients (p < 0.001). Therefore, participants who had been exposed to gout or hyperuricemia patients (8.0, IQR 7.0–9.0) had better grasp about gout than those without exposure (7.0, IQR 6.0–8.0, p = 0.001). Additionally, participants interested in gout-associated specialties (8.0, IRQ 7.0–9.0) scored higher than those interested in other specialties (8.0, IRQ 6.0–8.0, p = 0.039). Although scores differed among participants from different medical schools, this difference was eliminated by subgroup analysis according to stage of study.

Participants rated their self-assessed understanding of gout and hyperuricemia at an average of 3.07 on a 5-point Likert scale, where 1 indicated “fully disagree” and 5 indicated “fully agree.” Approximately one-quarter (98/363, 27.0%) believed they had sufficient knowledge, whereas 71/363 participants (19.6%) disagreed with this statement. The main sources of knowledge were class attendance (85.5%), informal online learning (55.7%), guidelines (36.4%), and medical journals (29.4%). Compared with rheumatoid arthritis, participants felt that they had a better understanding of gout but a worse understanding of hyperuricemia. Regarding ULT, 35 out of 363 (9.6%) participants reported that they knew all three commonly used drugs (allopurinol, febuxostat, and benzbromarone); 10/363 (2.7%) said that they knew about lesinurad or pegloticase. Over half (198/363, 54.5%) agreed that gout is a serious condition, whereas only 27.3% considered hyperuricemia to be severe. Participants’ perceptions of current management strategies were moderate, with average Likert scores of 3.23 for gout and 3.06 for hyperuricemia, respectively (Table 3 ).

Table 3.

Questions on beliefs and education of gout

Statement	Perception, n (%)
	Agreea	Fair	Disagreeb	Average scorec
I know enough about gout and hyperuricemia.	98 (27.00)	194 (53.44)	71 (19.56)	3.07
Gout is a severe condition.	198 (54.55)	152 (41.87)	13 (3.58)	3.6
Hyperuricemia is a severe condition.	99 (27.27)	190 (52.34)	74 (20.39)	3.09
The current management of gout is successful.	118 (32.51)	200 (55.09)	45 (12.40)	3.23
The current management of hyperuricemia is successful.	88 (24.24)	204 (56.20)	71 (19.56)	3.06

^a Agree = Fully agree/Agree, ^b Disagree = Disagree/Fully disagree, ^c The average score of Likert scale (scale from 1 to 5 represents fully disagree to fully agree) was calculated

Discussion

Although numerous studies have assessed physicians’ knowledge of gout [14–18], to our knowledge, this is the first study to investigate Chinese medical students’ perceptions of gout and hyperuricemia. Our findings indicate that while students possess a basic understanding of these conditions, they are often uncertain about the use of ULT and drug-induced hyperuricemia. The self-assessments also revealed a lack of confidence in their understanding of gout and hyperuricemia. In addition, this study explored students’ attitudes toward the severity of these conditions and how different learning sources contributed to their understanding.

In our study, only a small proportion of students (12.9%) correctly identified both that the goal of gout treatment is to lower SUA levels to below 6 mg/dL and that lifelong ULT is necessary. These accuracy rates were slightly lower than those previously reported among clinical physicians [14–18]. Most students (90.4%) acknowledged unfamiliarity with the commonly used first-line ULTs in China, and very few were aware of alternative agents such as lesinurad or pegloticase. As gout is a treatable condition, long-term ULT using a treat-to-target approach can dissolve monosodium urate crystals, prevent flares, and improve quality of life. This strategy is conditionally recommended by major rheumatology societies, with a SUA target of 6 mg/dL as the predominant threshold [21, 22]. However, gout management remains suboptimal worldwide; many patients continue to experience recurrent flares without receiving appropriate ULT. Even among those prescribed ULT, only about half maintain consistent therapy, and only a third achieve target SUA levels [23]. These findings reveal a significant knowledge gap among future healthcare providers and raise concerns regarding their preparedness to manage gout effectively [9]. Therefore, core principles of ULT should be emphasized in undergraduate medical education.

Among all 11 items assessing gout-related perceptions, students performed worst on the item regarding medications that increase SUA levels. This may be partially due to the multiple-response question. Notably, nearly 40% of students selected “not sure,” indicating a substantial knowledge deficit. With drug-induced hyperuricemia and gout becoming increasingly prevalent across a wide range of diseases [24, 25], it is essential that medical students learn to identify causative agents and appropriately manage elevated SUA, regardless of their intended specialty.

Students’ self-assessments further confirmed their limited confidence in the knowledge of gout and hyperuricemia, aligning with investigations among medical students in Australia and Croatia. These studies also highlighted students’ difficulties in addressing complex clinical scenarios, such as asymptomatic hyperuricemia and chronic gout [20, 26]. Educational theory suggests that recognizing knowledge gaps and a perceived need for improvement are key drivers of intrinsic motivation [27, 28]. When paired with appropriate educational opportunities, this motivation may enhance both knowledge retention and clinical competence.

Despite recognition of existing knowledge gaps, students’ self-assessments regarding disease severity point to a distinct and worrisome challenge for medical education. In this study, students rated the severity of gout as moderate to severe (mean Likert score: 3.6/5), while hyperuricemia was perceived as less serious (mean: 3.09/5). These findings should be interpreted with caution, as no comparator diseases were provided. The relatively low ratings may reflect a limited understanding of the disease burden associated with gout and hyperuricemia, given that knowledge has been shown to influence attitudes [29]. Alternatively, these perceptions may stem from the traditionally low prestige assigned to these conditions within the medical community. Chronic diseases that affect the lower body, involve fewer visible interventions, and predominantly impact older adults are often perceived as low-prestige [30]. Such perceptions may undermine students’ academic interest and potentially affect their future clinical performance [27].

The source of learning had a significant impact on students’ perceptions. Those who learned through both classroom instruction and clinical guidelines reported higher gout-related perception scores (median: 8.0, IQR: 7.0–9.0) compared to those who relied solely on classroom learning (median: 7.0, IQR: 6.0–8.0, p < 0.001). In contrast, informal online learning was not associated with improved scores (p = 0.625). Previous studies have reported limited awareness of current guidelines among both medical students [20, 26] and physicians [31]. Our findings further underscore the importance of guideline-based education in shaping clinical understanding.

Limitations of the study

Certain limitations of this study should be acknowledged. Regarding participant recruitment, despite efforts to include medical students from various regions and educational systems, Chinese medical education landscape is vast and heterogeneous [32]. The use of a snowball sampling strategy and a limited sample size may compromise the representativeness of the findings and limit the generalizability of the results to other settings or the national level. In addition, the study did not account for students’ rural or urban backgrounds, which may influence their knowledge and perceptions of gout. Regarding questionnaire design, the instrument was adapted from a previously validated tool [13] widely used to assess Chinese physicians’ understanding of gout and hyperuricemia. However, it was originally developed to evaluate patients’ knowledge of these conditions. Some items showed relatively low intraclass correlation coefficients, raising concerns about reliability. The inclusion of multiple-response question and options such as “None of the above is correct” may have introduced ambiguity. These questions capture only students’ understanding of gout and hyperuricemia, and may therefore provide an incomplete picture of their knowledge in related areas. Traditional Chinese Medicine—including oral herbal therapies, acupuncture, and transdermal patches—has an increasingly recognized role in gout management [33], yet this domain was not addressed in the current questionnaire. This remains an important area for future investigation. In addition, we excluded questions on gout medication dosages due to inconsistencies across clinical guidelines, which may have led to an overestimation of students’ competence in disease management. Future research should involve the development of a questionnaire tailored to medical students and employ large-scale, multi-center surveys with more diverse and representative samples. Such efforts would provide more robust evidence to inform curriculum development in medical education.

Conclusions

This study evaluated the perceptions of a sample of Chinese medical students regarding gout and hyperuricemia. The results suggest a relative lack of understanding of gout management, especially ULT and drug-induced hyperuricemia among these students, a finding that warrants further investigation in future studies. If there are plans to strengthen gout education, it is recommended to encourage medical students to consult clinical guidelines and to develop a more accurate understanding of the severity of gout and hyperuricemia.

Abbreviations

ULT

Urate-lowering therapy

SUA

Serum uric acid

NSAIDs

Non-steroidal anti-inflammatory drugs

Authors’ contributions

Y.W. (Youyang Wang) carried out the studies, participated in collecting data, drafted the manuscript, performed the statistical analysis, and participated in its design. Y.W. (Yibo Wang), Y.Y., X.H., and N.X. participated in the acquisition, analysis, or interpretation of data. Y.Z. and X.Z. critically revised and approved the final version of the article. All authors reviewed and approved the final manuscript.

Funding

This work was supported by Teaching Reform Project of PUMC (Grand No. 2023zlgl010), Peking Union Medical College Hospital Outstanding Young Talent Development Program (UBJ10806), Beijing Key Clinical Specialty Program, and QunGong Scholar Programme from Peking Union Medical College Education Foundation, Beijing, China.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding authors on reasonable request.

Declarations

Ethics approval and consent to participate

The Peking Union Medical College Hospital Ethics Committee exempted this study from ethics approval (I-23ZM0010). Informed consent was obtained from all subjects.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.