**E**ff**ects of Context and Virtual Reality Environments on the Wine Tasting Experience, Acceptability, and Emotional Responses of Consumers**

**Damir D. Torrico 1,2,\* , Yitao Han 1 , Chetan Sharma 2 , Sigfredo Fuentes 1 , Claudia Gonzalez Viejo 1 and Frank R. Dunshea 1**

Received: 24 January 2020; Accepted: 10 February 2020; Published: 14 February 2020

**Abstract:** Wine tasting is a multidimensional experience that includes contextual information from tasting environments. Formal sensory tastings are limited by the use of booths that lack ecological validity and engagement. Virtual reality (VR) can overcome this limitation by simulating different environmental contexts. Perception, sensory acceptability, and emotional responses of a Cabernet Sauvignon wine under traditional sensory booths, contextual environments, and VR simulations were evaluated and compared. Participants (*N* = 53) performed evaluations under five conditions: (1) traditional booths, (2) bright-restaurant (real environment with bright lights), (3) dark-restaurant (real environment with dimly lit candles), (4) bright-VR (VR restaurant with bright lights), and (5) dark-VR (VR restaurant with dimly lit candles). Participants rated the acceptability of aroma, sweetness, acidity, astringency, mouthfeel, aftertaste, and overall liking (9-point hedonic scale), and intensities of sweetness, acidity, and astringency (15-point unstructured line-scale). Results showed that context (booths, real, or VR) affected the perception of the wine's floral aroma (dark-VR = 8.6 vs. booths = 7.5). Liking of the sensory attributes did not change under different environmental conditions. Emotional responses under bright-VR were associated with "free", "glad", and "enthusiastic"; however, under traditional booths, they were related to "polite" and "secure". "Nostalgic" and "daring" were associated with dark-VR. VR can be used to understand contextual effects on consumer perceptions.

**Keywords:** virtual reality; acceptability; Cabernet Sauvignon; wine; context; emotions


4.2.3. Produced Wave Power

The wave energy was captured by PTO system. The relative heave velocity from both codes are similar to each other (Figure 7a). From Equation (19), the damping force can be observed in Figure 7b. Based on the relative heave velocity and damping force, the produced wave power could be identified, which is similar from F2A results and AQWA results (Figure 7c).

**Figure 7.** Time series of different responses of the combined structure under regular waves: (**a**) Relative Heave Velocity; (**b**) Damping Force; (**c**) Produced Power.

Under only wave conditions, F2A and AQWA had good consistency in simulations of the multibody dynamic response. This was because F2A integrates the AQWA hydrodynamic module.

#### *4.3. Irregular Wave and Turbulent Wind Conditions*

This section presents the motion response, mooring force, and produced power under irregular wave and turbulent wind conditions.

#### 4.3.1. Motion Response

Figure 8 shows the motion response in surge, pitch, and heave directions under normal operation conditions in LC2 and LC3. The responses of surge and pitch in both load cases from F2A (Figure 8a,b) simulation are smaller than those predicted by AQWA (Figure 8e,f). This is due to the fact that the wind load in F2A and AQWA is differently implemented. In F2A, the wind field is pre-generated and both wind aerodynamic load and damping are considered due to the rotating turbine rotor. However, in AQWA, the wind load is implemented as an external load using dll function and no interaction and aerodynamic damping is included. The difference for the relative heave motions simulated by two tools was limited for both LC2 and LC3 (Figure 8c,d).

**Figure 8.** Time domain motion response of the semisubmersible platform: (**a**) Surge in LC2; (**b**) Surge in LC3; (**c**) Relative Heave in LC2; (**d**) Relative Heave in LC3; (**e**) Pitch in LC2; (**f**) Pitch in LC3.

Figure 9 shows motion response in LC4, in which the wind speed is larger than rated wind speed. Similar as the load case LC2 and LC3, the motion responses in surge and pitch direction from F2A are lower than those motions from AQWA due to the aerodynamic damping. The relative heave motions predicted from two codes are similar to each other.

**Figure 9.** Motion responses of the semisubmersible platform in LC4: (**a**) Surge; (**b**) Relative Heave; (**c**) Pitch.

4.3.2. Mooring Line Force

The mooring line forces of ML1 and ML2 from LC2, LC3, and LC4 were compared for F2A results and AQWA in Figure 10. Basically, the mooring line force of ML2 in the upwind direction is larger than the mooring line force of ML1 in the downwind direction because wind and wave will drive the combined system to move in a downwind direction from its equilibrium position. Therefore, ML1 will get relaxed and ML2 will get tensioned. For the mooring line force of ML1, the reduction of the mooring force from its force at equilibrium position from F2A simulation is less than the reduction of the force from AQWA simulation due to the difference of the surge motions from two codes in all three load cases. Thus, the mooring line forces of ML1 from F2A are larger than those from AQWA (Figure 10a,c,e). However, for mooring line force of ML2, the increasing of the mooring force from its force at equilibrium position from F2A simulation is less than the increasing of force from AQWA simulation. Therefore, the mooring line forces of ML2 from F2A are less than those from AQWA (Figure 10b,d,f). Due to the pitch control above the rated wind speed (LC4), the wind thrust force is much smaller than that in LC2 (below rated wind speed) and LC3 (at rated wind speed). Therefore, the aerodynamic damping effect is much smaller. In this case (LC4), the contribution from wave load is much larger than wind load, and the discrepancy from two codes is minimal. Therefore, there is a slight difference in the mooring line force of ML2 for LC4.

**Figure 10.** Mooring force of: (**a**) ML1 in LC2, (**b**) ML2 in LC2, (**c**) ML1 in LC3, (**d**) ML2 in LC3, (**e**) ML1 in LC4, (**f**) ML2 in LC4.

4.3.3. Produced Wave Power

The relative heave velocities between the semisubmersible platform and the WEC, the damping force and produced power from WEC in LC2, LC3, and LC4, are presented in Figure 11. Due to less effect of aerodynamic damping on heave motion, no significant difference is identified for the relative heave velocities, damping force, and produced power. When the wave height increases from LC2 to LC4, the relative heave velocity (Figure 11a,c,e) also increases due to the large relative heave motion in a severe sea state, which is beneficial to capture wave energy. Figure 11b,d,f present the vertical damping force. The F2A and AQWA simulation results were similar. As the wave height increases, the vertical damping force increases significantly. Figure 11g,h,i show the produced energy power from WEC. With the sea state moving from mild to severe (LC2 to LC4), more power can be produced from the wave. Figure 11i is the produced power under severe sea conditions (LC4). It can be seen the maximum power in LC4 is even as large as 3.5 MW (not shown in Figure 11f), which is comparable to the power produced from the wind turbine. However, the mean produced power is less than 600 kW, and it shows obvious instability, while the produced power of WEC is much smaller. Therefore, the wind power production for NREL 5 MW WT will make the main contribution to the total power production of the combined system under the severe sea conditions.

**Figure 11.** Time series of different responses of the combined structure: (**a**) Relative Heave Velocity of LC2, (**b**) Damping Force of LC2, (**c**) Relative Heave Velocity of LC3, (**d**) Damping Force of LC3, (**e**) Relative Heave Velocity of LC4, (**f**) Damping Force of LC4, (**g**) Produced Power of LC2, (**h**) Produced Power of LC3, (**i**) Produced Power of LC4.

4.3.4. Statistical Analysis

Figure 12 displays the statistics of responses in operational conditions from both F2A simulation and AQWA simulation. The maximum and minimum values are determined as the highest crest and lowest trough of the corresponding time series. Figure 12a–c show that the simulation results of F2A and AQWA were different in the surge and pitch motion, and the heave motion results were slightly different, which was consistent with the previous results. When the wind velocity was the rated wind velocity of the wind turbine (12.4 m/s), the surge and pitch motion amplitudes of the platform were the largest, and the heave motion was greatly affected by the hydrodynamic load. When the wave height increases (LC2–LC4), the heave amplitude increases accordingly. Figure 12d shows that under the three operational conditions, the statistical values of the mooring force of ML2 simulated by F2A and AQWA were slightly different. Similarly, when the wind velocity was the rated wind velocity of 12.4 m/s (LC3), the mooring force of ML2 was the largest. Figure 12e shows that as the sea state becomes worse (LC2–LC4), the damping force and the produced power increase sharply. By comparing, aerodynamic loads were confirmed to have significant effects on surge and pitch motion and mooring forces, while hydrodynamic loads had significant effects on the vertical responses (heave, damping force, and produced power).

**Figure 12.** Comparison of the statistical results of in LC2, LC3, LC4: (**a**) Surge Motion; (**b**) Relative Heave Motion; (**c**) Pitch Motion; (**d**) Mooring Force of ML1 and ML2; (**e**) Damping Force (Df) and Produced Power (Pp).

02


**10. Final considerations**

Newborns with risk factors for neonatal hypoglycemia or those which, although not considered at risk, exhibit poor suckling or inadequate breast milk intake should receive follow-up monitoring and care after hospital discharge, so as to prevent possible undetected hypoglycemia.


**5. Market readiness of the WBA use as supplementary cementitious material**

In order to explore the market readiness and capacity for using WBA as SCM in the concrete industry, a questionnaire was conducted among 11 concrete producers (SMEs) from Croatia with an approximate annual concrete production of at least 12,000 m3 to a maximum of 300,000 m3. The purpose of the questionnaire was to conduct a qualitative study of concrete and cement production and the views of SMEs on the reuse of WBA in their plants. According to the results of the survey, the most common strength classes in concrete production are C25/30 and C30/37 (each represented by 91%), followed by 64% of concrete use of strength classes C20/25, C35/45, and C40/50 (**Figure 7a**). The compressive strength of concrete is a common and important property in the design of concrete structures. In addition to compressive strength as a basic property of concrete,

**Figure 7.**

*(a) Concrete production share with respect to the compressive strength class; and (b) cement type share in the concrete production.*

all respondents indicate water permeability. Other main properties most tested on hardened concrete are freeze-thaw resistance with or without de-icing salt (82%), wear resistance (82%), and chemical resistance (73%).

The average amount of cement used in concrete ranges from 295 to 340 kg per 1 m3 of concrete. 27% of the respondents use mineral admixtures in the production of concrete namely silica fume, coal fly ash, and metakaolin. The most common types of cement used in concrete production are shown in **Figure 7b** (multiple answers were possible): of the 15 types of cement on the market, blended cements are the most common: CEM II /A(B)-M(S-V) and CEM II /A(B)-S with 45% of use, CEM II /A(B)-M(S-LL, V-LL) with 27%, CEM II /A(B)-LL with 18% and CEM III /A(B, C), with 18%. Blended cements contain waste products as SCMs to replace clinker as the main source of CO2 emissions in concrete production [69]. By using SCMs could result in CO2 reduction of about 400 million tons per year [70]. These can be easily replicated as a possible circular solution for WBA management, which was recognized by concrete producers: 55% of respondents are familiar with the problem of WBA management and 91% of them are interested in using WBA in their plants. Concrete producers emphasized ensuring a consistent chemical and physical WBA quality to ensure the quality of the concrete produced.

Considering the current quantities of WBA in Croatia (25,414 tons per year [3]) and the data from the questionnaire analysis of cement and concrete production, all WBA can be used in cement and concrete production with regular quality control. For example, if 10% of cement is replaced by WBA, it is possible to reuse 1500 t of WBA per year in only one concrete plant with an average production of 50,000 m3 concrete/year. This means that in the four concrete plants the whole amount of the finer WBA can be used, while the coarser fraction can be used as a substitute for the fine fraction of aggregates (sand).

### **6. Conclusions**

According to all observed trends, waste ash from wood biomass combustion is expected to increase and the regulatory framework for waste management is becoming more stringent. In the design and planning phase of biomass power plants, it is important to determine the amounts of WBA generated and to find sustainable solutions for WBA management during the life cycle of the power plant. In the concrete industry, there is a high potential for substitution of certain components by adequate alternative materials, and in that context, the use of WBA has been examined. This paper presents comprehensive research of the properties of WBA necessary for its use as SCM in concrete. Based on the review of existing research and results of experimental testing shown in the paper, it can be expected that WBA reduces the workability of the cement composites, noting that cement replacement up to 10% has no significant effect on the consistency. This is probably due to the morphology of WBA, high alkali content, and LOI values. Increased setting time can also be expected, although results vary depending on the type of WBA used. For WBAs with a high CaO content, it is necessary to check the free CaO as it may affect the volume stability and durability properties of the cement composites. The comparison of the compressive strength of mortars and concretes shows a significant variability and influence of the different WBAs used on the compressive strength after 28 days with a tendency to decrease the compressive strength with a higher proportion of WBA.

*Utilization of Wood Biomass Ash in Concrete Industry DOI: http://dx.doi.org/10.5772/intechopen.102549*

The main logistical and long-term challenges that need to be considered when establishing an industrial symbiosis for sustainable WBA management are to ensure consistent WBA quality (proper storage and transportation of WBA from power suppliers to concrete producers); different types of WBA collection in power plants (e.g. mixing with water), which could affect WBA properties (self-hardening) and the need for additional pre-treatment of some WBA samples (e.g., grinding and/or screening) due to inefficient combustion of wood biomass or due to wood impurities, which could negatively affect durability properties.


**Acknowledgements**

We would like to thank the Georgia Department of Agriculture for funding this research through a Specialty Crop Block Grant titled: *SmartPhone Apps for Scheduling Irrigation in Six Specialty Crops*. We would also like to thank the University of Florida for developing the SmartIrrigation™ used in these experiments.


Invited Commentary on Leadership in Graduate Medical Education

**13**

**Chapter 2**

Education

*Jay M. Yanoff*

**1. Introduction**

**Abstract**

Leadership in Graduate Medical

Graduate medical education (GME) is a very complex endeavor within an even more complex healthcare system. This chapter examines many questions that need to be considered and the role of the key individual with oversight of the GME, the designated institutional official (DIO). Topics examined are the leadership theories, practices and strategies for the DIO, dealing with change when the DIO starts, using authority versus power, effective problem-solving and decision-making, adaptive leadership style, the historical function of the DIO, as well as the many tools available to the DIO including networking. The chapter concludes with several pearls of wisdom to positively help the DIO meet the many challenges of this very important role in GME.

**Keywords:** graduate medical education (GME), designated institutional official (DIO),

Graduate Medical Education (GME) is a very complex operation within an even more complex healthcare system. In order to be an effective leader within both a complex operation and system, there are many questions that need to be considered. For example, what is the purpose of having GME programs in the organization? What are both the long term and short term goals of the institution? What are expectations and outcomes sought by having GME programs? In some cases, what is the relationship between the hospital doing the training and any medical school who has oversight of the education? Since there are often multiple personalities with whom one must work, who are the leaders and participants and what are their values and expectations? In this complex environment, what are other relationships where you must interact such as accrediting bodies, affiliated institutions and other training institutions in your area? These questions stem from the very origins of developing any curriculum and plan for instruction and should be used as starting points to be a successful educational leader [1]. In order to be a successful leader in today's GME world, one must first recognize that this is not a simple role and requires skills,

leadership, dealing with change, problem-solving and decision-making

knowledge and the right temperament to deal with a multitude of issues.

In the middle of this complex system is the role of the designated institutional official (DIO). In this role, there are many individuals across the institution with whom the DIO interacts. Organizationally, the DIO is responsible for reporting to

**2. The role of the designated institutional official (DIO)**

#### **Chapter 2**

## Leadership in Graduate Medical Education

*Jay M. Yanoff*

#### **Abstract**

Graduate medical education (GME) is a very complex endeavor within an even more complex healthcare system. This chapter examines many questions that need to be considered and the role of the key individual with oversight of the GME, the designated institutional official (DIO). Topics examined are the leadership theories, practices and strategies for the DIO, dealing with change when the DIO starts, using authority versus power, effective problem-solving and decision-making, adaptive leadership style, the historical function of the DIO, as well as the many tools available to the DIO including networking. The chapter concludes with several pearls of wisdom to positively help the DIO meet the many challenges of this very important role in GME.

**Keywords:** graduate medical education (GME), designated institutional official (DIO), leadership, dealing with change, problem-solving and decision-making

#### **1. Introduction**

Graduate Medical Education (GME) is a very complex operation within an even more complex healthcare system. In order to be an effective leader within both a complex operation and system, there are many questions that need to be considered. For example, what is the purpose of having GME programs in the organization? What are both the long term and short term goals of the institution? What are expectations and outcomes sought by having GME programs? In some cases, what is the relationship between the hospital doing the training and any medical school who has oversight of the education? Since there are often multiple personalities with whom one must work, who are the leaders and participants and what are their values and expectations? In this complex environment, what are other relationships where you must interact such as accrediting bodies, affiliated institutions and other training institutions in your area? These questions stem from the very origins of developing any curriculum and plan for instruction and should be used as starting points to be a successful educational leader [1]. In order to be a successful leader in today's GME world, one must first recognize that this is not a simple role and requires skills, knowledge and the right temperament to deal with a multitude of issues.

#### **2. The role of the designated institutional official (DIO)**

In the middle of this complex system is the role of the designated institutional official (DIO). In this role, there are many individuals across the institution with whom the DIO interacts. Organizationally, the DIO is responsible for reporting to the Board of Directors of the institution (generally, a hospital), at least one medical school, hospital administration including the Chief Executive Officer, Chief Financial Officer, Chief Human Resources Officer, accrediting body requirements (in medical education, the ACGME), as well as the Centers for Medicare and Medicaid Services (CMS) and other funding sources to name a few of the most important ones. There are also consequences when there are issues of non-compliance that can lead to reduced governmental funding, loss of accreditation, National Residency Match Program (NRMP) match violations, and low resident and faculty morale.

In terms of an organization's power system, the DIO works primarily in the middle but also flexes into various Tops, Bottoms, Middles, and Customer roles [2]. DIOs as Tops have designated responsibilities (ex. accreditation), as Bottoms experience problems that we think higher-ups should take care of (ex. residency clinic operations), as Middles experience competing demands and priorities (ex. service versus education), and as Customers when we are looking to another department for a service we need to move our work ahead (ex. HR support to onboard new trainees). The DIO constantly toggles in and out of Top, Middle, Bottom, and Customer roles. In each of these roles, there are unique opportunities for contributing to organizational effectiveness and pitfalls that readily lead us to forfeit those contributions. The DIO's job within an organization's power system is to recognize and mitigate common reflex responses such as taking on too much responsibility when we are the Top, holding higher-ups too responsible when we are the Bottom, losing our connectivity with other parts of the organization when we are the Middle, and not participating enough in improving internal service delivery when we are the Customer [2].

In terms of oversight, there are many who have reporting relationships with the DIO including Program Directors of each internship, residency and fellowship program, Program Coordinators, DIOs at both sending and receiving institutions, oversight of the office of GME and most importantly, the education and training of interns, residents and fellows. Furthermore, the DIO is responsible for the Graduate Medical Education Committee (GMEC), the Clinical Learning Environment, and multiple other responsibilities demanded by the accrediting bodies including completion of affiliation agreements, compliance with work hours, initiating and maintaining wellness programs, encouraging and supporting scholarly activity, oversight of moonlighting, continual review of the educational programs, identifying "red flags" and then addressing the concerns, and any citations with proactive strategies and action plans. Needless to say, the role of GME leader in this very complex "middle person" system requires much knowledge, strong interpersonal skills and highly ethical values to be successful.

After many years serving as the Associate Dean for Graduate Medical Education at a medical school, Vice President for Academic Affairs at a hospital, and Chief Graduate Medical Education Officer (DIO) for the last 18 years at a medical school/ hospital, I want to reflect on those theories, practices and strategies that I have utilized which may help others who are in this complex "middle person" leadership role.

#### **3. Leadership theories, practices and strategies**

My definition of leadership is followership. Unless we can get others to follow, we cannot lead. Goffee and Jones coined the phrase, "Authentic Followership" explaining that leaders need to convey Authenticity, Significance, Excitement, and Community to followers in order to truly lead [3]. I believe that people want to follow someone who is "authentic," someone who they can trust, someone who will actively listen and hear their issues, and someone who believes in action, not just

**15**

*Leadership in Graduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.85736*

with whom we interact.

their leader?

**4. Dealing with change**

role, responsibilities and actions.

words. True leadership takes time to develop and is not accomplished overnight. Flexibility is a key component to building trust and caring relationships with those

One of the first questions to think about is what if you are new at an institution and are entering for the first time. I believe that you need to look at three levels of maturity: (1) your experience, professional background and leadership ability, (2) the institution's maturity, and (3) the employees experience and background with whom you will be working. Analyze how experienced you are in the DIO role. Ask some of the following: have you been in this role before? What was the size of the institution? How experienced do you feel? Regarding the institution: what is its historical background? How much does the administration of the institution know about GME and what is their support? How long have they had GME programs? What is the accreditation status of the programs? And finally, regarding the people at the institution: what is the maturity of the individuals in the Office of GME? What is the range of experience of the Program Directors and Coordinators? What do they expect from

There are several key thoughts here. Let us assume you have been in GME for many years and are considered mature. If so and you are entering a new system, you can take a directive role of leadership because you are the most mature. However, that is rarely the case. In most cases, the leader is entering a mature system, one that has been in existence for a long period of time with the employees and Program Directors already in place. The leader is a newcomer to the system irrespective of his/her maturity. In that case, the leader has to enter very gently. The leader needs to meet with key people, listen carefully, ask many questions, assess their needs, and ask what they expect from you and how you can help them. If possible, you may want to meet with the person who preceded you to learn as much as you can about the system from that person's perspective. Note, when coming into a new system, it is important to ingratiate yourself to those around you until such time as you can

I also believe that organizations, like people, have difficulty dealing with change. Organizational management experts note that basically, people resist change [4]. The greater the change, the stronger the resistance. Change is inevitable, but so is the resistance. Thus, if you are coming into a new institution, you must be prepared for the reaction to you. As the new person, there is an expectation that there will be change. I believe that organizations go through the same stages of change similar to those described by Elisabeth Kubler-Ross when referring to those experiencing death and dying. The stages are (1) denial, (2) anger, (3) bargaining, (4) depression and finally (5) acceptance [5]. It is reasonable to expect these earlier stages will occur with a new DIO entering an institution before there is acceptance of his/her

As the middle person in a complex system, where do we start. I have learned several things in my career. In a previous role, I sent out a questionnaire to many individuals that would take 5 minutes to complete. None were returned to me. In frustration, I called and asked if I could come to speak with them for a few minutes. In every case, the person said yes and the conversations often lasted an hour with much valuable information gained. What I leaned from this was to go to their space where they are comfortable, secure and open. Another example comes from early in my career when I was a 27 year old principal of an elementary school. Being young, inexperienced and in a role of responsibility, I developed a philosophy of

gain the respect of those with whom you will be leading.

#### *Leadership in Graduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.85736*

*Contemporary Topics in Graduate Medical Education*

we are the Customer [2].

skills and highly ethical values to be successful.

**3. Leadership theories, practices and strategies**

the Board of Directors of the institution (generally, a hospital), at least one medical school, hospital administration including the Chief Executive Officer, Chief Financial Officer, Chief Human Resources Officer, accrediting body requirements (in medical education, the ACGME), as well as the Centers for Medicare and Medicaid Services (CMS) and other funding sources to name a few of the most important ones. There are also consequences when there are issues of non-compliance that can lead to reduced governmental funding, loss of accreditation, National Residency Match

Program (NRMP) match violations, and low resident and faculty morale.

In terms of an organization's power system, the DIO works primarily in the middle but also flexes into various Tops, Bottoms, Middles, and Customer roles [2]. DIOs as Tops have designated responsibilities (ex. accreditation), as Bottoms experience problems that we think higher-ups should take care of (ex. residency clinic operations), as Middles experience competing demands and priorities (ex. service versus education), and as Customers when we are looking to another department for a service we need to move our work ahead (ex. HR support to onboard new trainees). The DIO constantly toggles in and out of Top, Middle, Bottom, and Customer roles. In each of these roles, there are unique opportunities for contributing to organizational effectiveness and pitfalls that readily lead us to forfeit those contributions. The DIO's job within an organization's power system is to recognize and mitigate common reflex responses such as taking on too much responsibility when we are the Top, holding higher-ups too responsible when we are the Bottom, losing our connectivity with other parts of the organization when we are the Middle, and not participating enough in improving internal service delivery when

In terms of oversight, there are many who have reporting relationships with the DIO including Program Directors of each internship, residency and fellowship program, Program Coordinators, DIOs at both sending and receiving institutions, oversight of the office of GME and most importantly, the education and training of interns, residents and fellows. Furthermore, the DIO is responsible for the Graduate Medical Education Committee (GMEC), the Clinical Learning Environment, and multiple other responsibilities demanded by the accrediting bodies including completion of affiliation agreements, compliance with work hours, initiating and maintaining wellness programs, encouraging and supporting scholarly activity, oversight of moonlighting, continual review of the educational programs, identifying "red flags" and then addressing the concerns, and any citations with proactive strategies and action plans. Needless to say, the role of GME leader in this very complex "middle person" system requires much knowledge, strong interpersonal

After many years serving as the Associate Dean for Graduate Medical Education at a medical school, Vice President for Academic Affairs at a hospital, and Chief Graduate Medical Education Officer (DIO) for the last 18 years at a medical school/ hospital, I want to reflect on those theories, practices and strategies that I have utilized which may help others who are in this complex "middle person" leadership role.

My definition of leadership is followership. Unless we can get others to follow, we cannot lead. Goffee and Jones coined the phrase, "Authentic Followership" explaining that leaders need to convey Authenticity, Significance, Excitement, and Community to followers in order to truly lead [3]. I believe that people want to follow someone who is "authentic," someone who they can trust, someone who will actively listen and hear their issues, and someone who believes in action, not just

**14**

words. True leadership takes time to develop and is not accomplished overnight. Flexibility is a key component to building trust and caring relationships with those with whom we interact.

One of the first questions to think about is what if you are new at an institution and are entering for the first time. I believe that you need to look at three levels of maturity: (1) your experience, professional background and leadership ability, (2) the institution's maturity, and (3) the employees experience and background with whom you will be working. Analyze how experienced you are in the DIO role. Ask some of the following: have you been in this role before? What was the size of the institution? How experienced do you feel? Regarding the institution: what is its historical background? How much does the administration of the institution know about GME and what is their support? How long have they had GME programs? What is the accreditation status of the programs? And finally, regarding the people at the institution: what is the maturity of the individuals in the Office of GME? What is the range of experience of the Program Directors and Coordinators? What do they expect from their leader?

There are several key thoughts here. Let us assume you have been in GME for many years and are considered mature. If so and you are entering a new system, you can take a directive role of leadership because you are the most mature. However, that is rarely the case. In most cases, the leader is entering a mature system, one that has been in existence for a long period of time with the employees and Program Directors already in place. The leader is a newcomer to the system irrespective of his/her maturity. In that case, the leader has to enter very gently. The leader needs to meet with key people, listen carefully, ask many questions, assess their needs, and ask what they expect from you and how you can help them. If possible, you may want to meet with the person who preceded you to learn as much as you can about the system from that person's perspective. Note, when coming into a new system, it is important to ingratiate yourself to those around you until such time as you can gain the respect of those with whom you will be leading.

#### **4. Dealing with change**

I also believe that organizations, like people, have difficulty dealing with change. Organizational management experts note that basically, people resist change [4]. The greater the change, the stronger the resistance. Change is inevitable, but so is the resistance. Thus, if you are coming into a new institution, you must be prepared for the reaction to you. As the new person, there is an expectation that there will be change. I believe that organizations go through the same stages of change similar to those described by Elisabeth Kubler-Ross when referring to those experiencing death and dying. The stages are (1) denial, (2) anger, (3) bargaining, (4) depression and finally (5) acceptance [5]. It is reasonable to expect these earlier stages will occur with a new DIO entering an institution before there is acceptance of his/her role, responsibilities and actions.

As the middle person in a complex system, where do we start. I have learned several things in my career. In a previous role, I sent out a questionnaire to many individuals that would take 5 minutes to complete. None were returned to me. In frustration, I called and asked if I could come to speak with them for a few minutes. In every case, the person said yes and the conversations often lasted an hour with much valuable information gained. What I leaned from this was to go to their space where they are comfortable, secure and open. Another example comes from early in my career when I was a 27 year old principal of an elementary school. Being young, inexperienced and in a role of responsibility, I developed a philosophy of

what I called "management by movement." I made sure I was in every classroom, every day. I believe that even though it is more comfortable to sit in our office and wait for issues to come to us, I am amazed with what gets accomplished by going to other people's space. By doing so, this facilitates building bridges and leads to more long-lasting relationships in the future. They are more comfortable and willing to share in their area than what may feel as intimidating when in my office/space. I use this strategy even to this day.

#### **5. Using authority versus power**

As a leader, I like to think of the difference between power and authority. Power is what you can make people do. Authority is what you can get people to do. Power is authoritarian and while it is needed sometimes, it often yields resentment and anger. I rarely ever wanted to use power to get things done, however when I had a trainee with drug or alcohol issues, it needed interventions immediately. I had to be more assertive and pull the person from service in order to get the individual the required assistance as soon as possible. However, in most cases, I want to use authority to get things done. I always want to base my relationships on trust, honesty, fairness and compassion to accomplish my goals and objectives and using power rarely yields this outcome.

#### **6. Effective problem-solving and decision-making**

A major aspect of leadership is problem-solving and decision-making. I often call upon Dewey's four stage model of problem-solving: (1) problem sensitivity (2) problem formulation (3) search and (4) resolution [6]. Problem sensitivity is the recognition that there is a problem in the first place. Problem formulation to me is the most important. Clearly determine what is the question being asked. If this is not articulated specifically in the beginning, we will search and not find the correct solution. It is important to make sure that the right question is being asked or an incorrect solution will be found and not be useful. If the problem formulation is carefully articulated, then a search can be made of alternatives and here is where I use a different model. I decide whether I want to maximize or satisfice. If I maximize, I want to generate as many options as possible and choose the best one. This takes time and should be used when making the most profound decisions. Some examples include:

Satisficing is generating options and deciding on the first satisfactory one. An example: we want to have a luncheon for the house staff. What kind of food should we order? The real issue here is deciding at the beginning if we want to maximize or satisfice. Many people make the mistake of maximizing on issues where they should satisfice and visa-versa.

As leaders, we are continually called upon to make decisions and solve problems. As a leader, I use the Dewey model in three ways—how I solve problems, what I expect from employees and how I deal with problem trainees.

**17**

*Leadership in Graduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.85736*

time and energy and yield better results.

and certainly do not play favorites.

**7. Adaptive leadership style**

then work with it not against it.

For me as the leader, I first try to articulate the problem as carefully as possible. I then determine if this requires maximizing or satisficing. I generate alternatives. If maximizing, I want as many alternatives as possible and want to pick the best solution. If satisficing, I accept the first alternative and move on. Leaders are best served who can differentiate and use these problem-solving skills. It will save much

When I first met new employees, I often shared this model with them. I indicated that I want them to think independently and want them to bring me problems they cannot solve themselves. So, when they came to me with a problem, I would ask them to articulate their thinking. I would then ask the person to tell me his/her resolution and invariably, the solution was almost always exactly what I would have selected. Both of us walk away being very satisfied with the process and the conclusion.

When I was dealing with trainees facing difficult situations and challenges, I tried very carefully to listen to what was the issue. I found several keys that I used in finding the problem resolution. The first step was, were they blaming others or were they taking some responsibility for the problem? If they were blaming others, I realized I could do little to help them. However, if they were seeing themselves as some part of the problem, I might be of some help. The second step was if they were taking some responsibility, were they willing to do something about it? If so, I could be of help. A former Dean for whom I worked called upon me for what he considered his most difficult problems. He indicated that after I investigated a problem (I used the Dewey method noted above), I was always "honest and fair." I think this is an important learning as a leader in GME that we are honest, fair and compassionate

It is important to note that no leadership style is best. I believe the best leaders are those who are able to evaluate the situation, be adaptive and use the appropriate style for the situation. I always tried to understand the styles of those above me and below me and adapt accordingly. An example—While I am an individual who thought about what I wanted in a meeting with my superior, I would prepare my rationale in advance in order to lead into my conclusion. However, when I met with him, he would constantly say, "Get to the point." I finally learned that I would present my conclusion first and if he wanted the particulars, I already had them prepared. Since there was a trust level between us, he would often accept my conclusion without an explanation. The lesson here is that we may have to adapt our style to meet the expectations of others if we want the positive results we desire. In other words, try to understand the dynamics between you and the other person and

I think that a leader must show high moral and ethical values. I think we all want to work with people like ourselves. How do we know if a person is like ourselves? I do not believe that it is one's gender, race, etc., but their values. When I interviewed a potential candidate, I ask the following: "Tell me about yourself." I am quiet and wait for an answer. I am not looking for what already is listed on his/her resume but rather any value words that I hear. If the candidate has difficulty articulating, I then ask them to give me 10 words that their best friend would use to describe them. I think we all want to work with people who have our same high values. Good team members are those individuals who have the same common goals and values.

Because the role of the DIO is so complex with multiple interrelationships, many responsibilities, time lines and expectations, time management is critical. Consider priorities and try to reduce chaos in the job. Obviously, we have all learned the value

#### *Leadership in Graduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.85736*

*Contemporary Topics in Graduate Medical Education*

this strategy even to this day.

**5. Using authority versus power**

power rarely yields this outcome.

**6. Effective problem-solving and decision-making**

new faculty to continue the program?

from employees and how I deal with problem trainees.

what I called "management by movement." I made sure I was in every classroom, every day. I believe that even though it is more comfortable to sit in our office and wait for issues to come to us, I am amazed with what gets accomplished by going to other people's space. By doing so, this facilitates building bridges and leads to more long-lasting relationships in the future. They are more comfortable and willing to share in their area than what may feel as intimidating when in my office/space. I use

As a leader, I like to think of the difference between power and authority. Power is what you can make people do. Authority is what you can get people to do. Power is authoritarian and while it is needed sometimes, it often yields resentment and anger. I rarely ever wanted to use power to get things done, however when I had a trainee with drug or alcohol issues, it needed interventions immediately. I had to be more assertive and pull the person from service in order to get the individual the required assistance as soon as possible. However, in most cases, I want to use authority to get things done. I always want to base my relationships on trust, honesty, fairness and compassion to accomplish my goals and objectives and using

A major aspect of leadership is problem-solving and decision-making. I often call

(2) problem formulation (3) search and (4) resolution [6]. Problem sensitivity is the recognition that there is a problem in the first place. Problem formulation to me is the most important. Clearly determine what is the question being asked. If this is not articulated specifically in the beginning, we will search and not find the correct solution. It is important to make sure that the right question is being asked or an incorrect solution will be found and not be useful. If the problem formulation is carefully articulated, then a search can be made of alternatives and here is where I use a different model. I decide whether I want to maximize or satisfice. If I maximize, I want to generate as many options as possible and choose the best one. This takes time and should be used when making the most profound decisions. Some examples include:

1.A program has lost some of its faculty to another institution. Should we

voluntarily withdraw the program and orphan the trainees or attempt to find

2.We have interviewed several people for the Program Director role. Each has

Satisficing is generating options and deciding on the first satisfactory one. An example: we want to have a luncheon for the house staff. What kind of food should we order? The real issue here is deciding at the beginning if we want to maximize or satisfice. Many people make the mistake of maximizing on issues where they should

As leaders, we are continually called upon to make decisions and solve problems. As a leader, I use the Dewey model in three ways—how I solve problems, what I expect

different strengths and weaknesses. Which one shall we choose?

upon Dewey's four stage model of problem-solving: (1) problem sensitivity

**16**

satisfice and visa-versa.

For me as the leader, I first try to articulate the problem as carefully as possible. I then determine if this requires maximizing or satisficing. I generate alternatives. If maximizing, I want as many alternatives as possible and want to pick the best solution. If satisficing, I accept the first alternative and move on. Leaders are best served who can differentiate and use these problem-solving skills. It will save much time and energy and yield better results.

When I first met new employees, I often shared this model with them. I indicated that I want them to think independently and want them to bring me problems they cannot solve themselves. So, when they came to me with a problem, I would ask them to articulate their thinking. I would then ask the person to tell me his/her resolution and invariably, the solution was almost always exactly what I would have selected. Both of us walk away being very satisfied with the process and the conclusion.

When I was dealing with trainees facing difficult situations and challenges, I tried very carefully to listen to what was the issue. I found several keys that I used in finding the problem resolution. The first step was, were they blaming others or were they taking some responsibility for the problem? If they were blaming others, I realized I could do little to help them. However, if they were seeing themselves as some part of the problem, I might be of some help. The second step was if they were taking some responsibility, were they willing to do something about it? If so, I could be of help.

A former Dean for whom I worked called upon me for what he considered his most difficult problems. He indicated that after I investigated a problem (I used the Dewey method noted above), I was always "honest and fair." I think this is an important learning as a leader in GME that we are honest, fair and compassionate and certainly do not play favorites.

#### **7. Adaptive leadership style**

It is important to note that no leadership style is best. I believe the best leaders are those who are able to evaluate the situation, be adaptive and use the appropriate style for the situation. I always tried to understand the styles of those above me and below me and adapt accordingly. An example—While I am an individual who thought about what I wanted in a meeting with my superior, I would prepare my rationale in advance in order to lead into my conclusion. However, when I met with him, he would constantly say, "Get to the point." I finally learned that I would present my conclusion first and if he wanted the particulars, I already had them prepared. Since there was a trust level between us, he would often accept my conclusion without an explanation. The lesson here is that we may have to adapt our style to meet the expectations of others if we want the positive results we desire. In other words, try to understand the dynamics between you and the other person and then work with it not against it.

I think that a leader must show high moral and ethical values. I think we all want to work with people like ourselves. How do we know if a person is like ourselves? I do not believe that it is one's gender, race, etc., but their values. When I interviewed a potential candidate, I ask the following: "Tell me about yourself." I am quiet and wait for an answer. I am not looking for what already is listed on his/her resume but rather any value words that I hear. If the candidate has difficulty articulating, I then ask them to give me 10 words that their best friend would use to describe them. I think we all want to work with people who have our same high values. Good team members are those individuals who have the same common goals and values.

Because the role of the DIO is so complex with multiple interrelationships, many responsibilities, time lines and expectations, time management is critical. Consider priorities and try to reduce chaos in the job. Obviously, we have all learned the value of making lists in medicine. Our minds will hold will not hold all the information we need nor the various tasks that need to be completed. Anticipate, plan ahead and complete tasks prior to the deadlines. Invariably other priorities will intercede so get things done as early as possible. This will reduce the natural stress of this very stressful job. Many years ago, I made a presentation at the Association for Humanistic Psychology entitled, "Slowing Down the Process and Learning to Ride Your Biocycle" [7]. The premise was that we have various times in the day when we are most productive and we should determine when those times are and work accordingly. I happen to be an early morning person who is less productive in late afternoon. As a result, I do my most important and creative work at those times when I feel most productive. We cannot work at maximum productivity all the time. Pick your best times and schedule the items that require your most attentive awareness during the most productive periods.

#### **8. Historical function of the DIO**

As a DIO, you are not alone. Years ago, there was no such role as a DIO. The ACGME simply required that every institution have "a designated institutional official" (lower case). Our own institutions did not know what that meant. However, with much pleading, the function was moved from a responsibility to a role. As such, the administrators at our institutions now know or should know what is required by this very important role. No institution can maintain its accreditation status without having a very competent individual in this very complex role.

#### **9. Using all the tools in your toolbox**

I grew up living above my father's hardware store. My grandfather was a very accomplished woodworker who made gavels for the United States Senate. Thus, I am a person who values tools. Tools make our lives easier. I believe that the more you use a tool, the more skilled and able you become. It is also important to use the right tool in the appropriate situation. A hammer and a screw driver do very different things. The ACGME provides many GME tools to help the DIO. There are also other tools in the market that make it easier to monitor work hours, evaluate residents, evaluate faculty, develop and maintain schedules, etc. Use them as they save time, energy and meet ACGME guidelines and requirements.

#### **10. Networking**

No DIO should minimize the importance of networking. As a result of our establishing a regional disaster plan, the DIOs in my area continue to meet to this day as a regional GME leadership group. There are now 23 institutions involved. Not only do we discuss the most pressing issues facing all of us, but we have contacts we can make with the DIOs of the other institutions who can help when problematic issues arise. Of course, we do not talk salary. However, we do discuss preparations for a CLER visit, how is your institution handling suicide prevention, how do you maintain confidentiality with feedback in very small programs, what is your process for the Annual Program Evaluations (APEs) and Annual Program Reports (APRs), and multiple other issues. On a regular basis, an institution will send out a query

**19**

*Leadership in Graduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.85736*

**11. Impact on trainees**

**12. Several pearls of wisdom**

to keep me sane.

be of help to others.

and is willing to help. Again, you are not alone.

regarding an issue and many respond with suggestions. Not only is it important to attend the national meetings, but local networking is an excellent tool for the DIO. If you have a question, there is some DIO out there who has had that situation

learned by experiencing positive, upbeat and sensitive leadership.

sometimes we may have a major impact on those with whom we interact.

There are three bits of advice I would like to share.

important and then move on to the next task at hand.

While the DIO role may seem overwhelming at times, there are many exciting parts to the job. I love to think of all the practicing physicians with whom I have helped in their careers. I once estimated that there are over 6000 physicians whose certificates I have signed and the enormous number of patients for whom they provide care. I have seen some of my former trainee leaders now become Program Directors and DIOs. They now model and emulate many of the values they have

In my career, I have measured impact of educational experiences. By impact, I mean that there is some external experience that changes the learner dramatically and internally. We rarely have the opportunity to know exactly the impact we are having on others. However, sometimes we are fortunate to find out. Recently, I received a call from a former student who indicated he was trying to find me because he was in the first class I taught 55 years ago. He indicated that I had made learning so much fun for him as a sixth grader that it influenced him to become a teacher, always make learning fun for his students. He indicated that he used this philosophy in teaching history, coaching and writing four books. It is nice to know that if we do the right things,

1.When I was in my early teens, I was required in school to learn a Rudyard Kipling poem entitled "If."  Throughout the chaos that we experience being in the middle of a complex system, this quote gives me guidance and strength

2.We are all achievers and want to accomplish much in the GME leadership role. One learns very quickly that everything cannot be accomplished immediately. Thus, I often remind myself of a Winston Churchill statement to Englander's during WW II, "It is better do something than nothing while waiting to do everything." As a GME leader, do not get mired in doing nothing and do what can be accomplished. Everything cannot be done at once. Start with the most

3.Finally, while you will have wellness programs for the house staff, take care of yourself. I often advise others that "Self-care is not selfish." If you are not healthy and let a role, job or responsibilities to disable you, then you will not be able to be of worth to the organization, your family or yourself. As noted many times above, this role is complex and you must take care of you so that you can

#### *Leadership in Graduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.85736*

*Contemporary Topics in Graduate Medical Education*

awareness during the most productive periods.

**8. Historical function of the DIO**

**9. Using all the tools in your toolbox**

energy and meet ACGME guidelines and requirements.

complex role.

**10. Networking**

of making lists in medicine. Our minds will hold will not hold all the information we need nor the various tasks that need to be completed. Anticipate, plan ahead and complete tasks prior to the deadlines. Invariably other priorities will intercede so get things done as early as possible. This will reduce the natural stress of this very stressful job. Many years ago, I made a presentation at the Association for Humanistic Psychology entitled, "Slowing Down the Process and Learning to Ride Your Biocycle" [7]. The premise was that we have various times in the day when we are most productive and we should determine when those times are and work accordingly. I happen to be an early morning person who is less productive in late afternoon. As a result, I do my most important and creative work at those times when I feel most productive. We cannot work at maximum productivity all the time. Pick your best times and schedule the items that require your most attentive

As a DIO, you are not alone. Years ago, there was no such role as a DIO. The ACGME simply required that every institution have "a designated institutional official" (lower case). Our own institutions did not know what that meant. However, with much pleading, the function was moved from a responsibility to a role. As such, the administrators at our institutions now know or should know what is required by this very important role. No institution can maintain its accreditation status without having a very competent individual in this very

I grew up living above my father's hardware store. My grandfather was a very accomplished woodworker who made gavels for the United States Senate. Thus, I am a person who values tools. Tools make our lives easier. I believe that the more you use a tool, the more skilled and able you become. It is also important to use the right tool in the appropriate situation. A hammer and a screw driver do very different things. The ACGME provides many GME tools to help the DIO. There are also other tools in the market that make it easier to monitor work hours, evaluate residents, evaluate faculty, develop and maintain schedules, etc. Use them as they save time,

No DIO should minimize the importance of networking. As a result of our establishing a regional disaster plan, the DIOs in my area continue to meet to this day as a regional GME leadership group. There are now 23 institutions involved. Not only do we discuss the most pressing issues facing all of us, but we have contacts we can make with the DIOs of the other institutions who can help when problematic issues arise. Of course, we do not talk salary. However, we do discuss preparations for a CLER visit, how is your institution handling suicide prevention, how do you maintain confidentiality with feedback in very small programs, what is your process for the Annual Program Evaluations (APEs) and Annual Program Reports (APRs), and multiple other issues. On a regular basis, an institution will send out a query

**18**

regarding an issue and many respond with suggestions. Not only is it important to attend the national meetings, but local networking is an excellent tool for the DIO. If you have a question, there is some DIO out there who has had that situation and is willing to help. Again, you are not alone.

While the DIO role may seem overwhelming at times, there are many exciting parts to the job. I love to think of all the practicing physicians with whom I have helped in their careers. I once estimated that there are over 6000 physicians whose certificates I have signed and the enormous number of patients for whom they provide care. I have seen some of my former trainee leaders now become Program Directors and DIOs. They now model and emulate many of the values they have learned by experiencing positive, upbeat and sensitive leadership.

#### **11. Impact on trainees**

In my career, I have measured impact of educational experiences. By impact, I mean that there is some external experience that changes the learner dramatically and internally. We rarely have the opportunity to know exactly the impact we are having on others. However, sometimes we are fortunate to find out. Recently, I received a call from a former student who indicated he was trying to find me because he was in the first class I taught 55 years ago. He indicated that I had made learning so much fun for him as a sixth grader that it influenced him to become a teacher, always make learning fun for his students. He indicated that he used this philosophy in teaching history, coaching and writing four books. It is nice to know that if we do the right things, sometimes we may have a major impact on those with whom we interact.

#### **12. Several pearls of wisdom**

There are three bits of advice I would like to share.

### **13. Conclusion**

In conclusion, I have tried to articulate the difficult middle role that the leader in graduate medical education must play. However, if the leader uses his/her knowledge of how the system works, and employs his/her skills, appropriate tools and strong personal values, the leader will have much of the pride, meaningful highlights, and success that I have felt in my career. The subsequent chapters in this book contain substantial and practical skills, tips, examples, and research for GME leaders to improve their effectiveness and overall impact. I feel that there can be no more satisfying and fulfilling job than being a good leader in graduate medical education.

Jay M. Yanoff, Ed.D. was the Chief GME Officer and Designated Institutional Official at Drexel University College of Medicine and Hahnemann University Hospital for 18 years.

### **Author details**

Jay M. Yanoff

Graduate Medical Education Officer, Designated Institutional Official, and Professor at Drexel University College of Medicine and Hahnemann University Hospital, Philadelphia, Pennsylvania, The United States of America

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**21**

*Leadership in Graduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.85736*

[1] Tyler RW. Basic Principles of Curriculum and Instruction. Chicago: University of Chicago Press; 1949

[2] Oshry B. Leading Systems: Lessons from the Power Lab. 1st ed. San Francisco, Calif. [Great Britain]: Berrett-Koehler Publishers; 1999

[3] Goffee R, Jones G. Why Should Anyone be Led by you? What it Takes to be an Authentic Leader. Boston, MA: Harvard Business School Press; 2006

W.B. Saunders Company; 1975

2011

Verlag; 1986

New York; 1975

[5] Kubler-Ross E. Questions and Answers on Death and Dying: A Companion Volume to on Death and Dying. Delran, NJ: Simon and Shuster;

[6] Yanoff JM, Bryan WE. Utilizing Lewinian principles for an institutional planning process within a medical school. In: By EHS, Whelan SA, editors. The Legacy of Kurt Lewin: Field Theory in Current Practice. New York: Springer-

[7] Yanoff JM and Hoffman RG. Slowing Down the Process and Learning to Ride your Biocycle. Paper presented to the Association for Humanistic Psychology;

[4] Hodgells RM. Management—Theory, Process and Practice. Philadelphia, PA:

**References**

*Leadership in Graduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.85736*

#### **References**

*Contemporary Topics in Graduate Medical Education*

In conclusion, I have tried to articulate the difficult middle role that the leader

Jay M. Yanoff, Ed.D. was the Chief GME Officer and Designated Institutional Official at Drexel University College of Medicine and Hahnemann University

in graduate medical education must play. However, if the leader uses his/her knowledge of how the system works, and employs his/her skills, appropriate tools and strong personal values, the leader will have much of the pride, meaningful highlights, and success that I have felt in my career. The subsequent chapters in this book contain substantial and practical skills, tips, examples, and research for GME leaders to improve their effectiveness and overall impact. I feel that there can be no more satisfying and fulfilling job than being a good leader in graduate medical

**13. Conclusion**

education.

Hospital for 18 years.

**Author details**

Jay M. Yanoff

**20**

provided the original work is properly cited.

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Graduate Medical Education Officer, Designated Institutional Official, and Professor at Drexel University College of Medicine and Hahnemann University

Hospital, Philadelphia, Pennsylvania, The United States of America

[1] Tyler RW. Basic Principles of Curriculum and Instruction. Chicago: University of Chicago Press; 1949

[2] Oshry B. Leading Systems: Lessons from the Power Lab. 1st ed. San Francisco, Calif. [Great Britain]: Berrett-Koehler Publishers; 1999

[3] Goffee R, Jones G. Why Should Anyone be Led by you? What it Takes to be an Authentic Leader. Boston, MA: Harvard Business School Press; 2006

[4] Hodgells RM. Management—Theory, Process and Practice. Philadelphia, PA: W.B. Saunders Company; 1975

[5] Kubler-Ross E. Questions and Answers on Death and Dying: A Companion Volume to on Death and Dying. Delran, NJ: Simon and Shuster; 2011

[6] Yanoff JM, Bryan WE. Utilizing Lewinian principles for an institutional planning process within a medical school. In: By EHS, Whelan SA, editors. The Legacy of Kurt Lewin: Field Theory in Current Practice. New York: Springer-Verlag; 1986

[7] Yanoff JM and Hoffman RG. Slowing Down the Process and Learning to Ride your Biocycle. Paper presented to the Association for Humanistic Psychology; New York; 1975

**23**

Section 3

Main Contents


**1.1 What is polymorphism?**

Polymorphism refers to the ability for the same compound to adopt multiple crystalline packing states. Organic molecules assemble into crystals by weak intermolecular interactions, typically via van der Waals and electrostatic interactions. Many thermodynamic and kinetics factors (such as temperature, solvent mixtures, speed of crystallization, seeding, and pH) can have significant impacts on crystal growth, leading to polymorphism prevalent among organic materials. For instance, a continuous investigation on polymorphism has indicated that approximately one-third of organic substances show polymorphism under normal pressure conditions [19, 20]. Different polymorphs often have distinct physical properties such as solubility, melting point, and electrical, optical, and mechanical properties [21]. The interest in polymorphism has increased significantly in recent years, particularly in the pharmaceutical and material science fields [17, 22].


**4.1 Socio-demographic characteristics of respondents**

In Beitbridge district, a total of 100 respondents successfully answered questionnaires, 50 were males and another 50 females. Respondents' age-groups ranged between 26 and 105 years who had lived within the district for 30 years or more and were believed to have witnessed considerable climatic and environmental changes. Like in other border districts in the south-western part of Zimbabwe, it was, however, easier to find female respondents than male ones. Most males and the youth go to neighbouring South Africa and Botswana to look for better employment and livelihood opportunities [17]. About 68% of the respondents were married, 18% were single and 10% were widowed, while 4% were divorcees. The level of education in the district is generally low, with 30% of the respondents having acquired only primary education, another 30% lower secondary level and 28% basic secondary education. Only 2% had advanced secondary level of education and 10% had tertiary training, 8% of whom being teachers and 2% agricultural extension officers. Average family size in Beitbridge was 6. About 52% of the respondents were unemployed and were typical agro-pastoralists who relied mainly on livestock and subsistence crop farming for their day-to-day household livelihood. About 26% were in part-time employment which mainly involved cross-border trading in household goods between Zimbabwe and South Africa. This group would shuttle weekly or monthly, by hook or by crook, legally or illegally between the two countries for their household livelihood. Only 22% were in formal employment, most of them being teachers or employed in other government departments like agriculture or Beitbridge Rural District Council employees.

#### *4.1.1 Evidence attributable to climate change in south-west Zimbabwe*

In Beitbridge district, there is a high realisation that the rainy season is now starting late (100%) and yet ending early (94%) (**Table 1**). This could be linked to the change in wind patterns which 80% of the respondents identified as having changed. Summer season is becoming hotter (80%), while winter is becoming warmer (64%). The apparent rise in temperature could partly be the reason for the drying of perennial

**41**

the third generation (**Figure 4**).

*Beitbridge Minority Farmer Communities and Climate Change: Prospects for Sustainability*

rivers and springs (78%) through increased evapotranspiration. Increased temperature can also help explain diminishing pastures (88%) through depletion in soil moisture. In an interview, Beitbridge Rural District Council Officer in charge of the central wards of Mtetengwe I, II and III, Mr. Sibanda (65) observed that early summer rains which used to start in September/October are now starting in December. June and July which are supposedly the coldest months of the year are no longer very cold. Instead, February, which is characteristically a very rainy month, is turning out to be very cold. Drought is now more frequent and temperatures are no longer predictable. Mr. Mudawu (70), a Shashe village elder in the western ward of Maramani, added that when the rains come, they are uncharacteristically erratic and cause lots of damages to bridges, schools, homes and even kill people and livestock through very violent and strong winds, flooding, lightning and thunder. Mrs. Simuta (64) of Chaswingo village in Dite I ward concurs that seasons have changed but added that this confuses farmers as to when to plant. Pastures in the eastern wards of Beitbridge comprising Dite I, Dite II and the Shangani-dominated Chipise are now few even if it rains. This has resulted in

In the Suthu-dominated north-western wards of Siyoka I, Siyoka II and Dendele, environmental evidence attributable to climate change include heavy siltation of Umzingwane River which used to be perennial with multiple permanent pools. The river no longer has any pools. According to Mr. Siziba (70) of Vuturura village (Dendele ward), harvests are now very poor yet in yesteryears grain used *ukubola eziphaleni ngobunengi babo* (grain used to rot in granaries because of huge harvests). Places like Lutumba village in central Beitbridge which used to successfully produce more dry land maize than pearl millet and sorghum no longer produce maize because of unreliable rainfall. Amacimbi (mopane worms) used to be plentiful in the whole district but because of low and variable amounts of rainfall, amacimbi have become fewer, smaller and as a result fetch much less income for the farmers than before. In very dry years, amacimbi die before maturity. Amarula juice, the

most common fruit product in Lutumba, has become less common.

*4.1.2 Meteorological evidence of climate change in Beitbridge district*

district has, therefore, become drier and hotter in recent years.

Harvests used to take place up to August but now they end in May. Wildlife, which used to be a common sight in the wards, has also disappeared partly because of negative variations in climate change-related environmental modification.

**Figures 2** and **3** show some descriptive evidence that Beitbridge is generally a dry district. Only 2 years (1952 and 1957) received annual rainfall above 500 mm in the generation 1952–1982. Comparatively, the third generation (1982–2012) had only 1 year (2000) receiving annual rainfall above 500 mm. The second generation had 19 years which received mean annual rainfall figures of 300 mm and below compared to the third generation's 21 years. The two climate graphs (**Figures 2** and **3**) also show that temperature range for Beitbridge increased from 1.4°C in the second generation (1952–1982) to 3.3°C in the third generation (1982–2012). Beitbridge

Rainfall is the most important climate variable in south-western Zimbabwe because of minority farmers' reliance on semi-nomadic pastoralism and rain-fed crop farming. Mean annual rainfall coefficient of variation was calculated in SPSS version 20 to determine the percentage variation from one generation to the next. Beitbridge district's mean annual rainfall coefficient of variation for the second generation (**Figure 3**) varied from as low as 35% in the second generation to 53% in

*DOI: http://dx.doi.org/10.5772/intechopen.83816*

many livestock deaths in recent years.

#### **Table 1.**

*Environmental evidence indicative of climate change in Beitbridge district.*

#### *Beitbridge Minority Farmer Communities and Climate Change: Prospects for Sustainability DOI: http://dx.doi.org/10.5772/intechopen.83816*

rivers and springs (78%) through increased evapotranspiration. Increased temperature can also help explain diminishing pastures (88%) through depletion in soil moisture.

In an interview, Beitbridge Rural District Council Officer in charge of the central wards of Mtetengwe I, II and III, Mr. Sibanda (65) observed that early summer rains which used to start in September/October are now starting in December. June and July which are supposedly the coldest months of the year are no longer very cold. Instead, February, which is characteristically a very rainy month, is turning out to be very cold. Drought is now more frequent and temperatures are no longer predictable. Mr. Mudawu (70), a Shashe village elder in the western ward of Maramani, added that when the rains come, they are uncharacteristically erratic and cause lots of damages to bridges, schools, homes and even kill people and livestock through very violent and strong winds, flooding, lightning and thunder. Mrs. Simuta (64) of Chaswingo village in Dite I ward concurs that seasons have changed but added that this confuses farmers as to when to plant. Pastures in the eastern wards of Beitbridge comprising Dite I, Dite II and the Shangani-dominated Chipise are now few even if it rains. This has resulted in many livestock deaths in recent years.

In the Suthu-dominated north-western wards of Siyoka I, Siyoka II and Dendele, environmental evidence attributable to climate change include heavy siltation of Umzingwane River which used to be perennial with multiple permanent pools. The river no longer has any pools. According to Mr. Siziba (70) of Vuturura village (Dendele ward), harvests are now very poor yet in yesteryears grain used *ukubola eziphaleni ngobunengi babo* (grain used to rot in granaries because of huge harvests).

Places like Lutumba village in central Beitbridge which used to successfully produce more dry land maize than pearl millet and sorghum no longer produce maize because of unreliable rainfall. Amacimbi (mopane worms) used to be plentiful in the whole district but because of low and variable amounts of rainfall, amacimbi have become fewer, smaller and as a result fetch much less income for the farmers than before. In very dry years, amacimbi die before maturity. Amarula juice, the most common fruit product in Lutumba, has become less common.

Harvests used to take place up to August but now they end in May. Wildlife, which used to be a common sight in the wards, has also disappeared partly because of negative variations in climate change-related environmental modification.

#### *4.1.2 Meteorological evidence of climate change in Beitbridge district*

**Figures 2** and **3** show some descriptive evidence that Beitbridge is generally a dry district. Only 2 years (1952 and 1957) received annual rainfall above 500 mm in the generation 1952–1982. Comparatively, the third generation (1982–2012) had only 1 year (2000) receiving annual rainfall above 500 mm. The second generation had 19 years which received mean annual rainfall figures of 300 mm and below compared to the third generation's 21 years. The two climate graphs (**Figures 2** and **3**) also show that temperature range for Beitbridge increased from 1.4°C in the second generation (1952–1982) to 3.3°C in the third generation (1982–2012). Beitbridge district has, therefore, become drier and hotter in recent years.

Rainfall is the most important climate variable in south-western Zimbabwe because of minority farmers' reliance on semi-nomadic pastoralism and rain-fed crop farming. Mean annual rainfall coefficient of variation was calculated in SPSS version 20 to determine the percentage variation from one generation to the next.

Beitbridge district's mean annual rainfall coefficient of variation for the second generation (**Figure 3**) varied from as low as 35% in the second generation to 53% in the third generation (**Figure 4**).

*Climate Change and Agriculture*

**4.1 Socio-demographic characteristics of respondents**

*4.1.1 Evidence attributable to climate change in south-west Zimbabwe*

*Environmental evidence indicative of climate change in Beitbridge district.*

In Beitbridge district, there is a high realisation that the rainy season is now starting late (100%) and yet ending early (94%) (**Table 1**). This could be linked to the change in wind patterns which 80% of the respondents identified as having changed. Summer season is becoming hotter (80%), while winter is becoming warmer (64%). The apparent rise in temperature could partly be the reason for the drying of perennial

**Ward number Ward name Ward number Ward name** Chipise 9 Machuchuta Dite 1 10 Dendele Dite 2 11 Siyoka 2 Mtetengwe 1 12 Siyoka 1 Mtetengwe 2 13 Leasnth Mtetengwe 3 14a Bishopstone Masera 14b Bishopstone Maramani 15 Old Tuli

In Beitbridge district, a total of 100 respondents successfully answered questionnaires, 50 were males and another 50 females. Respondents' age-groups ranged between 26 and 105 years who had lived within the district for 30 years or more and were believed to have witnessed considerable climatic and environmental changes. Like in other border districts in the south-western part of Zimbabwe, it was, however, easier to find female respondents than male ones. Most males and the youth go to neighbouring South Africa and Botswana to look for better employment and livelihood opportunities [17]. About 68% of the respondents were married, 18% were single and 10% were widowed, while 4% were divorcees. The level of education in the district is generally low, with 30% of the respondents having acquired only primary education, another 30% lower secondary level and 28% basic secondary education. Only 2% had advanced secondary level of education and 10% had tertiary training, 8% of whom being teachers and 2% agricultural extension officers. Average family size in Beitbridge was 6. About 52% of the respondents were unemployed and were typical agro-pastoralists who relied mainly on livestock and subsistence crop farming for their day-to-day household livelihood. About 26% were in part-time employment which mainly involved cross-border trading in household goods between Zimbabwe and South Africa. This group would shuttle weekly or monthly, by hook or by crook, legally or illegally between the two countries for their household livelihood. Only 22% were in formal employment, most of them being teachers or employed in other government departments like agriculture or Beitbridge Rural District Council

**4. Results**

employees.

**40**

*N = 100.*

**Table 1.**

*Source: generated by author.*

**Figure 2.** *Mean annual rainfall-temperature graph for Beitbridge district (1982–2012). Data source: Meteorological Department, Harare.*


**1. Introduction**

Important areas such as environmental sciences, medicine, medicinal chemistry, and cellular biology are dependent on very sensitive analytical techniques to detect and track biomolecules (amino acids, peptides, proteins, antibodies, oligonucleotides, nucleic acids, carbohydrates, and other biological molecules). Many of these techniques often require labelling with reporters or sensors, such as isotope labels [1], radioactive tracers [2], colorimetric biosensors [3], photoswitchable biomaterials [4], photochromic compounds [5, 6], electrochemical sensors [7], or fluorescent labels [8, 9]. The fluorescent labelling presents numerous advantages, when compared to the other techniques, due to the high sensitivity of the fluorescence technique and also due to its non-destructive nature that allows the use of small sample quantities and their fluorescent labels. The fluorescence process occurs in certain molecules called fluorophores or fluorescent dyes, and a fluorescent probe is nothing more than a fluorophore enabled to detect particular components of complex biomolecular assemblies, including live cells, with complex sensitivity and selectivity [10]. The organic fluorophores may form covalent

or non-covalent linkages with the sample to be analyzed, producing the respective bioconjugates (or complexes) that can show fluorescence, from short to very long wavelengths, depending on the label used. The bioconjugation technique depends on two interrelated chemistries: the reactive functionality present on the fluorescent label and the functional groups present on the target biomolecules to be labeled. The knowledge of the basic mechanisms by which the reactive groups couple to target functionalities provides the means to intelligently design the bioconjugation strategy. Choosing the correct fluorescent label that can react with the chemical groups available on target biomolecules forms the basis for successful labelling [11].

In general, the fluorescent label should be small in size and chemically stable, with minimal interference on the structure and biological functions of the unlabeled biomolecules, producing high fluorescence quantum yield bioconjugates.

On the other hand, the labelling reaction should be extremely efficient with high yields, preferably establishing a stable covalent linkage between the fluorescent label and a specific residue in the target biomolecule. The efficiency and selectivity of several fluorescent-labeled biomolecules have been used to study and understand their dynamics, kinetics, and photophysical properties [12–18].

The amine reactive fluorescent labels are the most frequently used to prepare stable bioconjugates to a great number of biological applications since amino groups are either abundant or easily introduced into biomolecules. In contrast, to study some particular protein structures and functions, thiol-reactive reagents are chosen due to the smaller presence of thiol groups, when compared with lysine, in biomolecules [19]. In this context, cysteine is generally the amino acid chosen to label when it is desired to label selectively a protein in vitro, due to its relatively low abundance and high nucleophilicity compared to other amino acid side chains. Specific and noninterfering dual fluorescent labelling in a peptide or protein molecule allows conformational investigations in terms of intramolecular distances [20].

The expeditious development of the fluorescent-labelling techniques allowed to explore and discover several cellular functions. To study, and understand, the activity of signal transduction by visualizing protein binding or folding, the fluorescence correlation spectroscopy (FCS) and the fluorescence resonance energy transfer (FRET) are widely used [21]. Molecular tags that specifically bind to particular membranepermeable dyes [22] allow to study protein dynamics and trafficking by fluorescence recovery after photobleaching (FRAP) as well the protein turnover [23, 24].

The great development of fluorescent-labelling techniques combined with the enormous technological advances in the field of fluorescence microscopy allowed to study, in vivo and in vitro systems, the protein distribution as well as their translocation and their interactions [25]. With specific and efficient fluorescent labelling, the proteins can be visualized in real time for the elucidation of their functions in a complex biological network, which also allows the detection of the protein-protein interactions, fundamental to understand intra- and intercellular communications [26].

Coumarins (benzopyranones or 2H-chromen-2-ones), whether natural products or synthetic ones, have also aroused a growing interest of the scientific community in the last decades due to their very significant pharmacological activity [27–37]. The nature and substitution pattern in the coumarins grant them diversified and exceptional optical properties with high fluorescence quantum yields [38]. Coumarins constitute the major class of fluorescent dyes [39–63], used as fluorescent labels and probes for physiological measurement [43–47], fluorescent whiteners [48], optical brighteners [49, 50], nonlinear optical chromophores [51–53], emission layers in organic light-emitting diodes (OLED) [54–57], and more recently, in caging [58–61], and labelling [62, 63]. Due to strong blue fluorescence of coumarin, it is easy to distinguish its light from green, yellow, and red,

**161**

*Coumarins as Fluorescent Labels of Biomolecules DOI: http://dx.doi.org/10.5772/intechopen.85973*

**2. Chemical labelling**

and the coumarins may play a leading role in this field.

**2.1 Amine reactive fluorescent coumarins**

concentration, and nontoxic reagents.

*2.1.1 Fluorescent coumarin succinimidyl esters*

an enormous advantage in multicolored fluorescence investigation. Developments from the last decade show that the introduction of appropriated substituents into the coumarin ring contributes to structures with improved photophysical and spectroscopic properties [64–66]. The synthesis of new fluorophores, with absorption and emission at long wavelengths, is of extreme importance for biological purposes,

Of all different fluorescent-labelling techniques, the chemical labelling is actually one of the most used as it allows novel types of experiments in biomolecules using a wider range of reactive fluorescent chromophores available. The covalent attachment of the chemical probes with specific amino acid has the advantage of being an irreversible process when compared to the non-covalent binding [67]. The chemical labelling methodology produces very stable bioconjugates, easy to manipulate with high efficiency, in a great number of available fluorophores that can be coupled covalently to the target biomolecule. Chemical labelling methods produce better results in in vitro studies rather than in vivo [18]. The most used methods in chemical labelling, in the biomolecules' native functional groups, under mild aqueous conditions, and using fluorescent coumarins, are discussed below.

Presently, amine reactive fluorescent coumarins are widely used to label biomolecules, as peptides, proteins, oligonucleotides, and nucleic acids, among others. The fluorescent bioconjugates obtained are very useful in fluorescence in situ hybridization (FISH), receptor labelling immunochemistry, cell tracing, and fluorescent analog cytochemistry studies. Almost all of the techniques used in these tests implicate a robust fluorescent conjugate able to support rigorous incubation, hybridization, and washing steps, which is provided by the stability of the covalent bond between the amine reactive dye and biomolecule. Chemically, the amine labelling reaction proceeds usually through acylation pathway producing stable amide (or thiourea) bonds. The "ideal" reactions are those which require the same conditions as proteins, like functional group tolerance, compatibility, selectivity, water as solvent (or pH ~ 7), room temperature, high reaction rates, low reactant

A number of fluorescent amino-reactive coumarins have been developed to label

various biomolecules, and the resultant conjugates are widely used in biological applications. Four major classes of amine-reactive fluorescent reagents are currently used to label biomolecules: succinimidyl esters (SE), 4-sulfotetrafluorophenyl (STP) esters, sulfonyl chlorides, and isothiocyanates [68]. **Figure 1** represents, in a general schematic diagram, the referred labelling reactions, between an amine

Succinimidyl esters (SE) are proven to be very good reagents for amine modifications. These kinds of reagents are generally stable and show good reactivity and selectivity with aliphatic amines, such as the amine group of lysine side chain. Some of these kinds of reactive dyes are hydrophobic molecules and should be previously dissolved in anhydrous dimethylformamide (DMF) or dimethylsulfoxide (DMSO), but the sulfo-succinimidyl esters are water soluble. The amine labelling

group of a biomolecule and a fluorescent amino-reactive coumarin.

an enormous advantage in multicolored fluorescence investigation. Developments from the last decade show that the introduction of appropriated substituents into the coumarin ring contributes to structures with improved photophysical and spectroscopic properties [64–66]. The synthesis of new fluorophores, with absorption and emission at long wavelengths, is of extreme importance for biological purposes, and the coumarins may play a leading role in this field.