Professor Jonathan Fallowfield: shortening the gap between bench and bedside

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Jonathan Fallowfield’s school careers advisor inadvertently did the field of liver research a big favour. When a young, sports-mad Jonathan told them he wanted to be a sports journalist they immediately poured cold water on the idea, telling him the field was too competitive and that he’d be better off doing something more vocational. Knowing that he liked biology, the advisor suggested he do medicine instead, dangling the carrot that he could always transition to medical journalism if the job didn’t suit. Jonathan, who admits he wasn’t especially passionate about academia as a boy, reluctantly agreed to this plan and pursued the sciences at A-level (plus English, just in case…), only to flunk his mock exams due to a lack of urgency. While scuppering any hopes his school harboured of Jonathan going to Oxbridge, Jonathan’s bad grades also scared him into working hard for the real thing; he achieved excellent grades, got into medical school and hasn’t dropped the pace since. Now the driving force of translational liver research at the University of Edinburgh’s Centre for Inflammation Research, it’s fair to say that journalism’s loss is hepatology’s gain.

Having discovered that the University of Southampton took a pioneering, systems-based approach to medicine that also prioritised early patient contact, Jonathan was impressed and made it his first choice for medical school. When he moved out of halls and into a shared flat for his second year, he found himself surrounded by very studious, high-achieving classmates, and their dedication proved infectious.

I got sucked into that atmosphere of competitiveness and studiousness. I started doing quite well, and I realised: it feels quite good doing well! So, I became super focused and ambitious from that point on.

In his third year Jonathan was doing a general medicine attachment at Southampton General Hospital’s liver unit and was deeply inspired by the dynamic group of clinicians who were leading it, such as Professors John Iredale and Michael Arthur. He also found himself fascinated by the liver itself, which seemed to him by far the most interesting and multifaceted organ.  

The liver performs more than a dozen basic functions that keep you alive, and that's before you get into the detail. It supports metabolism, digestion, immunity, detoxification, and it's very interesting when it goes wrong. I remember thinking then that I wanted to know more, and I aspired to work with these brilliant people who had built a pioneering research group.

Jonathan was soon presented with the ideal opportunity via an intercalated Bachelor of Science (BSc) degree with Dr Nick Sheron, a move that gave him “the bug for research” and made him determined to return one day to do a PhD in hepatology.

Jonathan’s BSc experience gave him a new confidence and determination. "I did everything I could after that to be very competitive. I wanted to work in the best places, for the best people." He completed his pre-registration House Officer placements in Southampton before applying to the Royal Brompton and Hammersmith Hospitals in London for his Senior House Officer (SHO) jobs. These hospitals formed two legs of the prestigious ‘golden circuit’ rotation, known as a hot bed of academic excellence, and it was apparent on arrival that Jonathan was in for a tough interview: several candidates before him had emerged from the interview room in tears, and when he entered he was amazed at the number of people on the panel, all of whom were the great and good of medical academia. Impostor syndrome began to creep in, but he had prepared and was offered the job.

Jonathan’s SHO circuit began with a baptism of fire. Having driven straight to the Royal Brompton from Southampton that morning he immediately went on call, but the shift was so grueling that by the time he finished he had accrued two days’ worth of parking tickets. "It was very daunting working there because the place was full of stellar people who had very high standards of patient care, and I didn’t want to mess up.” Jonathan credits the experience with instilling in him a strong work ethic and a commitment to pursuing clinical research.

If there was ever a nagging doubt about whether I wanted to be an academic or not, everything was solidified when I was at the Royal Brompton and Hammersmith. I thought, this is what I want to do. I want to be like these people.

After his SHO year in London was over Jonathan completed a further year of SHO training in Oxford before taking up Specialist Registrar positions in Jersey, Bournemouth, and Winchester, but after three years he decided it was time to do that PhD he’d promised himself as an undergrad. With the help of prospective supervisors Professor Arthur and Professor Iredale he successfully applied to the MRC for a Clinical Research Training Fellowship in the University of Southampton’s Liver Research Group. Jonathan was thrilled to be doing research at last, but he was somewhat thrown when both of his supervisors left to take up positions elsewhere. Professor Iredale, who had moved to the University of Edinburgh, assured Jonathan that he would stay involved, and he would later prove instrumental in bringing Jonathan to Edinburgh.

After gaining his PhD and completing medical training, Jonathan was acutely aware that he’d been away from the lab for over two years and felt it might hurt his chances of securing an academic post. Instead, and with the hope of getting involved in clinical research, he focused on getting a consultant post in a teaching hospital. He contacted Professor Iredale to ask him for a reference, but Professor Iredale proceeded to talk him out of it and asked him to consider moving to Edinburgh to pursue an academic career instead. After being shown around the Royal Infirmary of Edinburgh and the Queen's Medical Research Institute (QMRI) by Professor Iredale and his colleague Professor Stuart Forbes, Jonathan was not only convinced but charmed. However, he needed a position. He met Professor Iredale at a liver conference soon after and sketched out the bones of a Clinician Scientist Fellowship (CSF) on a napkin, before going home to flesh the application out. Having been funded by MRC twice before he was mortified to subsequently be turned down, but  tried again with a new CSF scheme from the Academy of Medical Sciences and the Health Foundation. Jonathan was successful, and he began his career at the University of Edinburgh in 2008.

On starting his CSF at Edinburgh Jonathan recognised that, while there were excellent basic scientists, and talented clinicians conducting clinical research, there was no-one bridging the two areas.

I felt there was an academic space between QMRI and the hospital that I could reside in,” he says, “So I decided to make that my niche, and develop research projects that had clear clinical line of sight.

Having both a clinical and research background, and a workload at Edinburgh that encompassed both, gave Jonathan a perspective that enabled him to come at areas of unmet need from two angles: the lab and the ward. In other words, he was perfectly positioned to carry out bench-to-bedside translational research.

One area of unmet clinical need that Jonathan has spent some time researching (strongly supported by colleague Professor Peter Hayes) is tackling complications related to the abnormal blood circulation in advanced liver disease – particularly improving kidney perfusion and function in patients with end-stage liver fibrosis (cirrhosis). He has been investigating the possible benefits of using the pregnancy hormone relaxin, which is a natural vasodilator and anti-fibrotic, in patients with cirrhosis. This work was initially beset by delays in securing synthetic relaxin, and it took no shortage of patience and perseverance from Jonathan to get to the point he’s at now: working with a newly-formed company who have made their own relaxin ‘mimetic’ and are conducting clinical trials. All being well, Jonathan will lead the team of Edinburgh clinicians who will recruit and treat hepatorenal syndrome patients with relaxin.

In 2018, Jonathan became a professor and was named the University of Edinburgh’s Chair of Translational Liver Research. While he continues to dedicate most of his time to research, Jonathan was keen to retain some clinical duties and spends between one and two days a week at the Royal Infirmary. Maintaining a balance between his clinical and research responsibilities, and maintaining excellence in both areas, is a perpetual challenge but one that Jonathan finds motivating.

Never comfortable resting on his laurels, Jonathan is now working with a liver pathology colleague Dr Tim Kendall on an ambitious precision medicine project (SteatoSITE: an integrated gene-to-outcome data commons for non-alcoholic fatty liver disease (NAFLD) research) – work that has been funded by two Innovate UK grants. To help him engage most effectively with the project and, more broadly, to maintain his leading edge, Jonathan is continuing his education by doing a Master's level course in health data science in his spare time. Although he’s at an advanced stage of his career, it’s clear that Jonathan’s ambition and his love of learning are undimmed.

I have to move with the times and ask myself: what’s next? The answer is big data and digital health technologies. So I want to learn more about health data science and how to do bioinformatics. I want to learn how to use R so I can keep up with my PhD students and be a better supervisor as well.