"I Had to Learn How to Stop Sacrificing Myself" | Dr. Tiffany Moon

Episode Overview

• Host Dr. Gabrielle Lyon and guest Dr. Tiffany Moon—a board-certified anesthesiologist and Associate Professor at UT Southwestern Medical Center practicing at Parkland Hospital (a Level 1 trauma center)—explore how a patient's baseline physiology, body composition, and cardiovascular fitness dictate their safety and drug dosing under anesthesia.
• The conversation demystifies operating room pharmacology and risk management, covering how adipose tissue alters drug distribution, why GLP-1 agonists require specialized airway protocols, how pain pathways function independently of consciousness, and what actually drives post-operative cognitive decline.
• Beyond clinical medicine, Dr. Moon shares her personal journey as a Chinese immigrant who entered college at age 15, her experience filming one season of The Real Housewives, and how missing key family milestones led her to deconstruct perfectionism, address gender disparities in medicine, and pivot toward work-life integration.
• Listeners will gain both a practical medical framework for preparing their bodies for surgery like an athletic event and actionable psychological strategies for overcoming the high-achiever "checklist" mentality.

Key Concepts

• Speaker Backgrounds, Disclosures, and Business Ties: Dr. Gabrielle Lyon is the author of the upcoming book The Forever Strong Woman and discloses episode sponsors Cozy Earth (bedding and sleepwear; code DRLYON for up to 20% off), Our Place (cookware, specifically the Titanium Pro pan; code DRLYON for 10% off), and Branch Basics (non-toxic cleaning supplies; code DRLYON for 15% off the Premium Starter Kit). Dr. Tiffany Moon graduated residency in 2012, served as Director of Resident Recruitment, and is the author of The Joy Prescription, owner of an anesthesia-named candle line (featuring "Ketamine" and "Propofol" candles), and creator/host of the CME-accredited Lead Her Retreat (formerly Lead Her Summit) for 20 to 30 women (down from 200 at previous summits; about 70% of attendees are physicians, alongside PAs, nurses, lawyers, and finance gurus). Dr. Moon also filmed 12 weeks (one season in 2021) on The Real Housewives, sits on a longevity board alongside Dr. Lyon, and is exploring a career pivot into longevity medicine and facial laser treatments.
• Body Composition and Anesthetic Pharmacology: Anesthesiology is the marriage of physiology and pharmacology ("80% science, 20% art"). At Parkland Hospital, the average patient BMI is 35 to 40, a BMI of 30 is considered "almost skinny," and an alarm does not go off in Dr. Moon's head unless a BMI exceeds 40. While Dr. Moon is personally around 25% body fat, many of her patients are 50% plus body fat (compared to a baseline example of 30%). A large fat mass creates a massive volume of distribution that acts as a "sink" absorbing lipophilic (fat-binding) drugs, and gives inhaled anesthetics a "longer tail" that requires turning off the gas sooner to avoid delayed emergence. Crucially, different drugs require different weight calculations: Succinylcholine (used for rapid sequence intubations in emergency surgery) must be dosed on total body weight, whereas Propofol (standard induction dose of 2 mg/kg) must be dosed on lean body mass. Dosing a 150-kilo morbidly obese patient (where 100 kilos is adipose tissue) on actual body weight causes a relative overdose and severe hypotension. Because nobody measures lean mass as a pre-op standard and DEXA scans only extrapolate the totality of lean body mass, anesthesiologists must "eyeball" lean mass.
• GLP-1 Agonists and Airway Management: Dr. Moon estimates a quarter (25%) of her patients are now on GLP-1 agonists. Holding all GLP-1s before surgery is no longer the universal recommendation, especially in emergencies. Instead, anesthesiologists can use gastric ultrasound to inspect the gastric outlet antrum—where solid food appears "snowflakey" and echodense, and fluid looks big, dark, and non-echogenic. If food is present, they perform a rapid sequence induction: administering induction drugs and paralytics rapidly and placing the cuffed endotracheal tube without mask-ventilating ("bagging") the patient in the interim to prevent pulmonary aspiration.
• Cardiovascular Reserve, Age Physiology, and Anesthesia Risk: Surgery is a major physiologic insult comparable to running a 10K or a marathon. Athletes have high cardiorespiratory fitness and lower baseline heart rates and blood pressures; under anesthesia, their vital signs look like "railroad tracks" (completely stable, like a jog on 5.0 on the treadmill). Conversely, unoptimized patients—such as those with an A1C of 12 or uncontrolled hypertension at 160/90—lack autoregulatory reserve. When put to sleep, a hypertensive patient's blood pressure plummets and fluctuates like a "roller coaster," which is why Dr. Moon spends 90% of her time administering vasopressors to bring blood pressure up rather than lowering it. Physiological reserve also varies drastically by age: at Parkland, the youngest patients Dr. Moon sees are 3 to 4 years old in the burn unit (neonates go to Children's Hospital), where a child's baseline heart rate is around 130 bpm and hits 160 bpm when upset; in contrast, if an adult ASA 3 or 4 vascular patient hits 160 bpm, they are "for sure going to have an MI" (myocardial infarction). For a healthy person undergoing elective surgery, the anesthesia mortality rate is less than 0.1% (lower than a car accident), though Dr. Moon hedges that she can never promise a patient won't die, and notes that critically ill patients may survive the OR on four vasopressors only to die in the ICU 24 hours later.
• Brain Perfusion and Post-Operative Cognitive Decline: Post-operative cognitive decline ("pump head") is highest in cardiopulmonary bypass (open-heart surgery), where the sternum is sawed open and the patient is placed on a heart-lung machine ("on pump") with a non-beating heart and very little cerebral perfusion; a 30-minute to 1-hour pump run is acceptable, whereas 1.5 to 2-hour pump times should be avoided. In non-cardiac surgeries, cognitive fuzziness is linked to periods of hypotension causing poor brain perfusion. Dr. Moon hedges that while she can directly monitor kidney perfusion via urine output through a Foley catheter, anesthesiologists lack a direct marker for brain perfusion and must assume that if the heart and kidneys are working, the brain is perfused as well.
• Consciousness vs. Pain Pathways and Modern Pharmacology: Consciousness (sleep/memory) and pain sensation operate on separate neurological pathways. An unconscious patient's body still senses surgical pain (such as everting a uterus during a hysterectomy), causing heart rate spikes and physical retraction unless analgesics and paralytics are given. Preemptively blocking this response is vital because once a pain pathway is activated, it can trigger post-op hyperalgesia (pain out of proportion to the injury) and chronic pain requiring Gabapentin and pain specialists. Only about five new anesthesia drugs have emerged recently: Sugammadex (emerged about a decade ago to reverse neuromuscular paralysis at the end of major surgery, replacing Neostigmine); three types of fentanyls—Fentanyl, Sufentanil, and Remifentanil (Remifentanil is over 10 years old, and Dr. Moon uses Fentanyl on 90% of her anesthetics); and Journavx, a new non-opioid selective sodium channel blocker that stops peripheral pain signals at the site before reaching the brain, useful for patients with addiction risks or those on opioid antagonists like Buprenorphine (Suboxone) (Dr. Lyon notes taking Journavx before a quantum facial laser procedure and feeling groggy afterward). Although Fentanyl is a synthetic opioid 100 times stronger than morphine (which is naturally derived from the opium poppy), Dr. Moon states that normal patients without a history of substance abuse will not get addicted when given it for painful surgeries like knee replacements or when taking post-op medications as prescribed—hedging that the idea of an addictive personality getting hooked from a single medical dose may be hyperbole, whereas injecting it to get high carries massive addictive potential.
• Genetics and Substance Use in the OR: Individual requirements for anesthesia vary based on genetics and substance exposure. Redheads require about 10% more anesthesia. Patients who drink heavily or use "uppers" (amphetamines, cocaine) have upregulated norepinephrine and epinephrine, putting them in a hyper-aware state that requires significantly more anesthesia to sedate. In contrast, cannabis/marijuana is "not terrible" regarding anesthesia risk compared to uppers. In trauma settings, poly-substance use complicates care: Dr. Moon cites a Level 1 trauma patient who wrapped his car around a pole at 70 mph whose urine toxicology ("U-tox") tested positive for six substances: amphetamines, cocaine, fentanyl, benzos, cannabis, and PCP (a ketamine derivative).
• Evolving Medical Dogma, Resident Selection, and Perfectionism: Medical paradigms frequently shift; for example, Dr. Lyon points out that the warning against eating eggs due to high cholesterol was removed from the 2015 Dietary Guidelines because dietary cholesterol does not translate to blood-level cholesterol. In academic medicine, Dr. Moon experienced a major paradigm shift during her first 5 years as Director of Resident Recruitment: initially ranking candidates by top board scores, research, and AOA status (top 10–15% of the class), she discovered many "great on paper" students were terrible in the OR due to poor hand-eye coordination, slow reaction times, and lack of situational awareness, while marginal-grade students with high emotional intelligence became her best residents. Personally, Dr. Moon's drive stemmed from her early life—born in China, raised by grandparents from age 3 to 6, flying as an unaccompanied minor from Beijing to JFK at age 6 speaking no English, attending 4 elementary schools, 3 middle schools, and 2 high schools, moving into a house at age 10, welcoming her brother at age 11, starting college at age 15 with 60 hours of incoming credit, and graduating in 4 semesters after an advisor said it was impossible. After spending over $10,000 (in 2008 dollars) applying for residency, marrying in 2012, having twin daughters in 2014 (now age 12, plus a stepdaughter who was 15 during COVID), and returning to the OR 6 weeks postpartum to do a liver transplant while pumping breast milk, she missed her daughter's first steps at 13 months old while working full-time, running 2 clinical trials, and taking trauma/transplant call. This prompted her to transition to part-time work around age 35. Both speakers hedge on the origins of perfectionism: Dr. Lyon notes it "may be somewhat of an inheritable trait, I'm not sure," while Dr. Moon believes it is mostly "nurture, not nature" and circumstantial, though she concedes there may be "a little bit of inheritable trait" after observing one of her twin daughters. Dr. Moon also highlights ongoing workplace inequities, noting that "there's studies that show" women are paid less than men for doing the same job, and points out the irony that being called an "embarrassment to the institution" for doing reality TV ultimately gave her the public platform to advocate for science, mentorship, and gender pay equity.

Quotes

• At 0:00:06 - "People who are uncontrolled hypertensive, they're 160 over 90, I put them to sleep, their blood pressure plummets. And so you look at the anesthesia record and it looks like a roller coaster. Versus a healthy person like you, presumably having surgery, we call it railroad tracks." - Dr. Moon explaining the counterintuitive reality that high baseline blood pressure leads to severe hypotensive drops under anesthesia due to poor autoregulatory reserve.
• At 0:00:43 - "Being told that I was a, quote-unquote, embarrassment to the institution when I decided to do 12 weeks of reality TV. You know, it was one season, like give me a break. Ironically, going on Real Housewives actually allowed me to then talk more about science and mentorship and equality in the workforce and the gender pay gap, which are topics that I'm passionate about, because all of a sudden somebody cared what I had to say." - Dr. Moon discussing the academic backlash to her television appearance and how it unexpectedly amplified her medical and advocacy platform.
• At 0:03:35 - "I would describe anesthesiology as the marriage of physiology and pharmacology, right? Like my job is to ensure that when a patient goes to sleep for surgery, that it's done in a safe manner, that the airway is secured, that their blood pressure is maintained, that blood is transfused when it needs to be, and then to at the end of surgery, magically hit some off button that the surgeons think we have, and they just wake up and go to the recovery room as if nothing happened." - Dr. Moon defining the core clinical responsibilities of an anesthesiologist in the operating room.
• At 0:05:27 - "So if your volume of distribution is large because you have a large fat mass, the lipophilic drugs will produce a sink and you will absorb more of that drug. Additionally, all of our inhaled anesthetic agents, if you are morbidly obese, last longer, meaning they have a longer tail. I have to turn the gas off sooner for our morbidly obese patients for them to wake up on time, or else we're going to have a really long delayed emergence." - Dr. Moon detailing how high body fat percentages alter the absorption and clearance times of anesthetic agents.
• At 0:07:28 - "If you slug a morbidly obese person with 2 milligrams per kilogram of propofol, which is our induction dose, but you dose it according to their actual body weight and they're 150 kilos, which is not uncommon at Parkland, that patient will have severe hypotension as a result of your relative overdose of propofol, because you should know that propofol should be dosed according to lean body mass and not total body mass." - Dr. Moon illustrating the critical clinical difference between dosing drugs on total body weight versus lean body mass.
• At 0:21:17 - "So we want to get you in tip-top shape to run a race. I said anesthesia is going to be like running a race. Some people are going to run a marathon, you're only doing a 10K today, it's just a little breast something, you know? So yours is a 10K. My guy in my other OR, he's running a marathon today, it's going to be all day, it's a big cancer case, liver, you know, resection, all this kind of stuff. So what race are you running and what shape are you in to run this race?" - Dr. Moon framing surgical preparation as athletic training depending on the complexity of the procedure.
• At 0:23:42 - "The thing with the kidneys is if you're making adequate urine output, which I can see because you have a Foley in your bladder and I'm looking how much you're peeing, I'm reassured that, oh, the kidneys are being perfused because I'm getting good urine. I don't really have a good marker for how well your brain is being perfused. It's just if the heart's working and the kidneys are working, surely the brain must be getting enough as well, but we don't actually have something." - Dr. Moon hedging on the limitations of intraoperative monitoring regarding cerebral perfusion and post-operative cognitive decline.
• At 0:25:43 - "If you are a healthy person undergoing elective surgery, the mortality with anesthesia is like less than 0.1%." - Dr. Moon providing statistical reassurance regarding the baseline safety of elective anesthesia for optimized patients.
• At 0:35:39 - "There's pain sensation, which is not the same thing as consciousness. The body still feels pain even though you're not conscious and you don't remember it. When a patient is not at an adequate depth of anesthesia or analgesia, which is pain control, and the surgeon does something, the heart rate spikes and I will give fentanyl." - Dr. Moon clarifying why unconscious patients still require strong analgesics to prevent physiological pain responses and post-op hyperalgesia.
• At 0:45:41 - "We had people that were great on paper, and then they showed up in the OR and I'm like, 'Oh my god.' Like bad hand-eye coordination, bad reaction time, like good on paper does not mean good in the OR. And then there were students that I almost did not give a chance to, and I'm so glad I did, because they had marginal grades, marginal, like okay, but not stellar, and I took a chance on them because they interviewed so well or just something hit me during their interview process. And some of those students ended up being my best anesthesia residents." - Dr. Moon sharing how her experience recruiting residents taught her to value emotional intelligence and situational awareness over pure academic metrics.
• At 0:59:00 - "These are all the things that young Tiffany thought that if she checked off of her list would bring her happiness. Like almost like a scorecard that when you check off all the boxes, you turn it in and get a prize. And it was like, go to the best college, go to the best medical school, you know, all those things, get married, have kids, own Louboutins, buy a Birkin, you know, and I'm like, check, check, check, check, check! And I'm like, 'Okay, I turn it in, I'm ready, I win!' And the universe was like, 'No, bitch, it doesn't work like that.'" - Dr. Moon reflecting on the illusion that external achievements and material milestones guarantee internal fulfillment.

Takeaways

• Train for elective surgery like an athletic race: Before going under anesthesia, prioritize resistance training, cardiovascular endurance, blood pressure control, and metabolic health (such as managing A1C and body fat percentage) so your vital signs remain stable ("railroad tracks") and your brain stays well-perfused during the procedure.
• Disclose GLP-1 usage and all substance history to your anesthesiologist: Always inform your surgical team if you take GLP-1 agonists so they can perform a pre-operative gastric ultrasound or use rapid sequence induction to prevent aspiration, and be completely transparent about alcohol, cannabis, or stimulant use (and even natural red hair) so they can accurately calibrate your sedative doses.
• Utilize appropriate pain control to prevent chronic post-op pain: Do not fear necessary intraoperative opioids like fentanyl or prescribed post-operative analgesics if you have no history of substance abuse; properly blocking acute surgical pain pathways prevents your nervous system from developing post-operative hyperalgesia and chronic pain, and patients with addiction concerns can ask their doctors about non-opioid peripheral blockers like Journavx.
• Evaluate talent beyond "on-paper" credentials: When hiring or recruiting for high-stakes environments, look past top test scores and academic accolades to assess practical execution, reaction time, situational awareness, and emotional intelligence.
• Audit your schedule before missing irreplaceable family milestones: If overworking and chasing academic or corporate prestige are causing you to miss pivotal moments in your children's lives, consider restructuring your career—such as dropping to part-time clinical hours or delegating responsibilities—to align your daily time with your core values.
• Abandon the perfectionist "scorecard" mentality: Stop treating educational degrees, career promotions, and luxury purchases as a checklist that will eventually purchase happiness; instead, cultivate deliberate daily joy and self-worth independent of external validation.