Medical licensing examination (uigwa) and the world of the physician officers (uigwan) in Korea’s Joseon Dynasty

Physicians for ordinary people in Korea’s Joseon Dynasty (1392-1910) did not need to pass the national medical licensing examination. They were able to work after a sufficient apprenticeship period. Only physician officers were licensed as technical civil servants. These physician officers were middle class, located socially between the nobility and the commoner. They had to pass a national licensing examination to be considered for high-ranking physician officer positions, that is, those at the rank equal to or above the 6th level out of a total of 9 ranks, where the first rank was highest. Royal physicians also had to pass this examination before accepting responsibility for the King’s healthcare. This article aims to describe the world of physician officers during the Joseon Dynasty. Physician officers enjoyed considerable social status because they dealt with matters of life and death. Owing to the professional nature of their fields and a strong sense of group identity, they came to compose a distinct social class. The physician officers’ world was marked by strong group allegiances based on shared professional knowledge; the use of marriage to gain and maintain social status; and the establishment of hereditary technical posts within the medical profession that were handed down from one generation to the next. The medical licensing examination persisted until 1894 when the civil service examination agency, of which it was part, was abolished. Until that time, the testing agency, the number of candidates who were accepted, two-step test procedures, and the method of test item selection were maintained and enforced.


INTRODUCTION
During Korea's Joseon Dynasty, physician officers (uigwan) played a vital role in people' s lives, as they had since early modern history.During that period of time, physicians for ordinary people did not need to pass Korea's medical licensing examination.However, to become a physician officer, one had to complete professional education and to pass a difficult qualifying examination.There existed a national licensing examination (gwageo) in several areas of occupational study (jab hak).The national licensing examination for technicians (jab gwa) was for officers who work in a variety of practical job.
The medical licensing examination (uigwa) was one of the national licensing examinations for technicians.Neither royal families nor the nobility could avoid sickness and death; therefore, they relied on these physician officers for care.Indeed, the physician officers enjoyed an increasing level of prestige by caring for the upper classes.However, during the Joseon Dynasty, the certified physician officers were solidly middle class.
They straddled the line between low-ranking technicians in charge of various medical health practices and high-level government medical experts.This article aims to review the medical profession of the Joseon Dynasty and discuss the social status of physician officers who passed the national medical licensing examination based on a review of the literature [1][2][3][4][5][6][7][8][9][10][11].

MEDICAL EDUCATION AND STUDENTS
Medicine was only a small part of the range of technical education available in Joseon society.Technical trainings were held at the office called Seogwanamun in Seoul and in the local offices of governing districts.The Ministry of Health (Jeon uigam) presided over medical education and the medical licensing examination and had responsibility for medical care in Seoul.Medical students were trained in the provinces outside Seoul.There were 50 students under the Ministry of Health and 30 students in the hospital for ordinary people (Hyemin seo), and 44 in the provinces outside Seoul.For those who received medical education, there were two ways to become physician officers: by passing a basic aptitude test (chwijae) or by passing a national licensing examination.Those who passed the basic aptitude test were appointed only to temporary positions.To be recognized as nationally certified physician officers, one needed to pass a more comprehensive state-administered medical licensing examination.Only physician officers who passed this licensing examination could be appointed as high-ranking medical officials equal to or above the rank of the 6th level (Jong6Pum) out of a total of 9 ranks, where the first rank was highest.Royal physicians also had to pass this certification before accepting responsibility for the King' s healthcare.
During the Joseon Dynasty, different social sectors of the population were served by specific physician officers.The Royal Hospital (Naeuiwon) was in charge of managing the royal family's medical care, occasionally offering such services to members of the King's court as well.The state health minister (Jejo) was in charge of medical treatment for the common people and soldiers, as well as serving members of the royal family and courtiers.Hyeminseo mainly undertook medical care of the general population, while the hospital for the poor (Hwa linseo) primarily served patients with infectious diseases, prisoners in the city, and the poor.Medical students were dispatched to the medical care facilities in the provinces, and they took charge of medical care.

MEDICAL LICENSING EXAMINATION TO BE A PHYSICIAN OFFCER
The medical licensing examination was implemented immediately after the founding of the Joseon Dynasty.It was conducted in the 6th year of King Taejo (1397) for the first time and administered a total of 233 times until it was abolished in the Reformation of Government system in 1894.Medical licensing examinations were held on an average of once every 2.2 years.It was executed not only on a regular basis (singnyeon) but also an irregular schedule (junggwangsi).The regular ex-amination was conducted once every three years.The irregular examination was specially conducted when a special memorable event happened to the nation.A separate large-scale irregular examination (daejunggwangsi) was conducted when a special memorable event occurred.The medical licensing examination was composed of two parts: the first step examination (chosi) and the second step examination (boksi).The first step examination was organized in the fall before the year of the regular examination by the state health minister.Regular and irregular examinations each passed the top 18 examinees, while the large-scale irregular examinations allowed 22 examinees to pass.The state health minister and two other officials in the Ministry of Health became examiners of the first step examination.The second step examination was held in Seoul in the spring of the regular examination year by the Ministry of Health.Only the top nine candidates could pass the regular and irregular examinations; while, 11 could pass the large-scale irregular examination.The examiners of the second step examination consisted of the state health minister, two government officials of the Minister of Health, two higher ranking officials of the Ceremonies Ministry, and each government official of the Investigators (Saheonbu) and Royal Consultant (Saganwon).Among the examinees, 18 from the first step examination could pass and nine from the second step examination could pass.However, it was rare to see nine examinees actually pass.The number who passed did not reach the full quota before the 19th century.What explains these phenomena?The examiners limited their selection to the candidates with excellent medical skills.Even if they did not choose to fill the quota, it was not a problem according to the law.
Applicants were tested on the contents of medical textbooks and the 1485 code of law (Gyeonggugdaejeon), and then underwent an oral examination.First, textbooks on examination of the pulse (Chandomaek) and on acupuncture and moxibustion had to be memorized.Second, the candidates were required to explain the meaning of the following medical textbooks immediately after reading them: a medical encyclopedia (Jik jibang), a textbook based on Chinese Yuan Dynasty medicine (Deukhyobang), obstetrics (Buindaejeon), chicken pox (Chang jinjib), obstetrics and gynecology (Taesanjipyo), herbal medicine (Gugeupbang), a textbook based on Chinese Song Dynasty medicine (Hwajebang), a general medical textbook (Bon cho), and the 1485 code of law.These test subjects were maintained until the middle of the 18th century, and were changed afterwards, when a code of law was enacted in 1746 (Sokdae jeon).Textbooks on examination of the pulse and on acupuncture and moxibustion had to be memorized, while Jikjibang, Boncho, and the 1485 code of law had to be explained after reading.The other textbooks were removed from the list of textbooks to be explained.Instead, a textbook based on Chihttp://jeehp.orgJ Educ Eval Health Prof 2015, 12: 16 • http://dx.doi.org/10.3352/jeehp.2015.12.16 nese Tang Dynasty medicine (Somun), one based on Chinese Ming Dynasty medicine (Uihakjeongjeon) and one on Chinese Yuan Dynasty medicine (Dongwonsipseo) were newly added.The test subjects of the first step examination and the second step examination during the regular and irregular examinations were the same.The same test subjects were repeated in each of two steps.
Those who passed the medical licensing examination received a formal letter of acceptance and were wined and dined by the Ceremonies Ministry.They were also invited to be guests of the royal palace on the day after passing.They performed in an event intended to show great respect to the King.The top ranking of the examinees who passed was appointed to the sub-8th rank (jong8pum); the second ranking one to the 9th ranking (jeong9pum), and the third, to the sub-9th ranking (Jong9pum) according to their examination scores.Those who passed the examination and who already had an official rank were promoted one level.

THE WORLD OF PHYSICIAN OFFICERS
There is a book containing a list of the names of those who passed the medical licensing examination during the Joseon Dynasty (Fig. 1).It shows the names of 1,548 examinees who passed, along with biographical information, including family of origin; residence at the time of the examination; educational background; career history; specifics regarding the examination; and the names and careers of their family members (Fig. 2).Owing to this book, it is possible to understand many aspects of these physician officers' entry into the public service, their social status, and their marital status.Physician officers were basically limited to being promoted to a higher rank according to an appointment system to a certain limited rank; therefore, ongoing promotion was not guaranteed.They could be promoted up to the sub-3rd rank (danghagwan, jeong3 pum).Although it is very difficult for them to reach the 3rd rank, but it occured in rare cases.There were many instances where physician officers were promoted after caring for the King or royal family.Such was the case of Jun Heo, a famous physician officer, who was a royal physician to King Seonjo and was appointed to the position of Deserving Retainer (ho seonggongsin) in 1604.He was later promoted to Top-Rank Officer (jeong1pum) in 1606.However, objections by members of the nobility led to the cancellation of this promotion.The promotion of physician officers up to high-ranking status frequently caused controversy in the Royal Court.Paradoxically, the prevalence of such controversies showed that there were many cases in which physician officers became high-ranking officers.They sometimes became local governors.The "An-  nual Record of King Sukjong" from1674 to 1720 in Annals of the Joseon Dynasty contains records showing that the position of local governor of Gyeonggi province was usually taken by a physician officer.However, physician officers did not just receive adequate rewards and promotions.If medical malpractice occurred, they were punished.In severe cases, complications during the treatment of the King might result in a death sentence to the physician officer.To avoid this situation, a royal physician limited his prescriptions mainly to Chinese herbal medicine, avoiding any drastic medication that could cause an unexpected reaction in his royal patients.
Owing to their social function and position, physician officers came to represent a very unique social class.They developed self-awareness of their unique place in the hierarchy.They compiled physician officers' Eight-Generation Pedigree (uig wapalsebo), their genealogy in the 19th century.In contrast to typical genealogies starting with the eldest ancestor and literally descending into the present, their genealogy noted the most recent descendant at the top, and the eight ancestors were listed in turn below.The physician officers' world was marked by strong group allegiances based on shared professional knowledge; the use of marriage to gain and maintain social status; and the establishment of hereditary technical posts within the medical profession that were handed down from one generation to the next.This latter feature is revealed in a common saying from the proverb, "Don't take medicine unless three generations become physicians" mentioned in the Annals of the Joseon Dynasty.Even though the phenomenon such as challenging and removing ranks was prominent beginning in the 19th century Joseon Dynasty, their social networking was patterned through succession and marriage.

CONCLUSION
Although physicians who cared for ordinary people did not need a medical license in the 500 years of Korea's Joseon Dynasty, to become physician officers, they had to pass the medical licensing examination.Although some textbooks for test subjects were changed in the 18th century, the following characteristics of the system were consistent for 500 years: the Ministry of Health as a leading agency; a maximum number of examinees allowed to pass, specifically 18 people in the first step examination and nine people in the second step examination; the two-step pass-fail test method; and the same method of administration for regular and irregular examinations.These characteristics of the examination were typical of other state technical certification examinations of the Joseon Dynasty.At the end of the 19th century in Korea, there was a rapid social and cultural change brought by introduction of modern cultures through China and Japan.The medical licensing ex-amination system of the Joseon Dynasty was completely abolished in 1894, which was the result of the implementation of new practices and medical practices known as Western medicine at that time.In the face of Western medicine armed with science and experimental procedures, the prestige of traditional medicine, known as Oriental medicine, dropped rapidly.Of course, the introduction of Western medicine did not occur all at once.Many people were intimidated by new and unfamiliar medical equipment and procedures.Some rejected these new practices outright.However, Western medicine's status and importance ultimately rose as it was proven to have a therapeutic effect on patient care, particularly in the surgical therapy of wounded soldiers.Therefore, Korean students began to learn Western medicine.In 1885, a Western-style hospital called Jejungwon was opened.In 1886, the Jejung Medical School was established and 16 medical students were recruited.Some people were insisting on the maintenance of the traditional medical system at the end of the 19th century; however, they were gradually ousted and traditional medicine was established as a complementary and alternative form.The physicians who learned and practiced the new modern medicine became, step by step, the leading professional intellectuals in Korea.

CONFLICT OF INTEREST
No potential conflict of interest relevant to the study was reported.

SUPPLEMENTARY MATERIAL
Audio recording of abstract.
Editorial comment: For the Romanization of Korean characters, all terms are spelled out according to the Korean Government Ministry of Culture and Tourism's Notice of Regulation 2000-8 (July 7, 2000) available from: http://www.korean.go.kr/.The automatic Romanization was done by a program available from: http://roman.cs.pusan.ac.kr/.If the reader prefers to read the terminology according to McCune-Reischauer Romanization, the same program available from http://roman.cs.pusan.ac.kr/ can be used.

Fig. 1 .
Fig. 1.Page of list of passers of medical licensing examination in Joseon Dynasty published in 1891 (Uigwabangmok) which shows the list of passers of the medical licensing examination (uigwa) from 1498 to 1891 with their score ranking and their father's job title and name.

Fig. 2 .
Fig. 2. Page of list of passers of medical licensing examination in Joseon Dynasty published in 1891 (Uigwabangmok) which shows the list of passers of the medical licensing examination (uigwa) from 1498 to 1891 with their family history and hometown.