Why I Left American Medicine After 15 Years with Dr. Sarah Mauthe Part I

When Your Green Card Becomes a Hostage Situation: Dr. Sarah Mauthe's Journey Through US Hospital Medicine

What happens when the very visa process meant to help you build a medical career in the United States becomes the thing holding you captive in a job you need to leave? That's the question at the heart of my conversation with Dr. Sarah Mauthe, a Canadian-born physician who trained at the University of Alabama, practiced hospital medicine across three very different corners of America, and eventually found her way back home to British Columbia.

I met Sarah while we were both on call at Royal Jubilee Hospital here in Victoria. One phone call about a patient question turned into a conversation about her remarkable path through American medicine, and I knew immediately her story needed to be shared with other physicians considering a similar move. This is part one of a three-part series, and today we're covering her training, her career across Alabama, Nevada, and California, and the immigration ordeal that no doctor should have to experience.

From Tuscaloosa to Mobile: Life as a Hospitalist in the Deep South

Sarah's path into medicine started in Canada, but a family move pulled her toward the United States for her clinical training. She landed at the University of Alabama for her family medicine residency, choosing hospitalist medicine specifically because it offered flexibility down the road.

What struck me most about Sarah's description of Tuscaloosa and later Mobile, Alabama, was her refusal to lean into stereotypes. She talked about culture shock, sure, unfamiliar phrases, a different pace of life, but she also talked about exceptional medical care, genuine friendships that have lasted well over a decade, and a community she grew to love. As she put it, people often assume healthcare quality in Alabama must be lacking simply because of regional stigma. Her experience said otherwise. The teaching hospitals and academic centers she worked alongside provided some of the best patient care she witnessed anywhere in her career.

This matters because so much of the conversation around physicians relocating gets flattened into simplistic narratives. Good people and good medicine exist everywhere, and bad systems can exist everywhere too. Sarah's story captures both truths without picking a side for the sake of a clean storyline.

Her early years as a hospitalist were, in her words, something she was "enamored with." She described a version of hospital medicine where physicians still had room to dig into a patient's full picture instead of being pushed to discharge by 10 a.m. or hand off incidental findings to outpatient follow-up. That changed when she was promoted to hospitalist director at a second facility in Mobile. Stepping into leadership meant seeing behind the curtain, and what she saw was a healthcare system quietly transforming in ways that made the job less sustainable year after year.

The Immigration Trap No One Warns You About

This is the part of Sarah's story that I think every physician considering a move to the US, or already working there on a visa, needs to hear. Sarah came in on an H-1B visa and applied for her green card the way most employer-sponsored physicians do. What should have taken one to two years stretched into four, with vague excuses from the company's law firm the entire time.

The truth came out, almost accidentally, during recruiting drinks when a company executive, after a few drinks, admitted that immigrant hires who hadn't yet received their green cards couldn't leave without forfeiting their applications. The company had been deliberately delaying her paperwork to keep her locked into the job.

Sarah's reaction was visceral, and understandably so. Physicians already make enormous personal sacrifices for their work: covering short-staffed shifts, attending recruiting dinners instead of being home with family, saying yes when every instinct says this isn't sustainable. To learn that an employer was weaponizing her immigration status on top of all that was, in her words, something she couldn't get past.

She hired her own immigration attorney, who confronted the law firm directly. Six months later, her green card came through. She gave her notice the same day.

I want to flag something important here for anyone following this journey toward working in Canada instead. The immigration horror stories coming out of the US system, doctors effectively held hostage by employers controlling their green card timelines, are not something we see in the Canadian system. Permanent residency processes through express entry are now frequently moving in two to four months. There are administrative hurdles here and there, certainly, but nobody is manipulating your paperwork to keep you trapped in a job.

Twenty-Four Days Alone Covering a 200-Bed Hospital

The consequences of Sarah's immigration status came into sharp focus when her hospitalist program in Mobile had a contract change that led every other physician on the team to quit. Sarah couldn't leave because she was still waiting on her green card. For roughly 24 days, she was the only hospitalist covering an entire 200-bed hospital, with no primary care physicians rounding and specialists admitting almost nothing outside their own services.

She described shifts running from 5 a.m. to midnight and days with 50 to 60 patients. The hospital hadn't anticipated anyone actually reaching those numbers, so a per-patient overage fee kicked in, which she says was the only silver lining she could hold onto during that stretch. What stood out to her, even in the middle of that crisis, was how her colleagues stepped up, covering consults and absorbing extra complexity so she wasn't completely alone.

Searching for a Better System: For-Profit, Nonprofit, and HMOs

After leaving Alabama, Sarah moved through Reno, Nevada, and eventually Palm Springs, California, chasing a theory that changing the type of healthcare system might fix what she was experiencing. She tried a for-profit hospital, then a not-for-profit system, then an HMO-based high-acuity clinic. Her conclusion, delivered with a fair amount of dry humor, was that the structure didn't matter nearly as much as she expected. The same payers, the same pressures around length of stay, the same administrative weight showed up regardless of the tax status printed on the hospital's paperwork.

Her time in Reno also coincided with the early months of COVID, adding PAPR suits, pay cuts, and the surreal experience of watching patients die without family present while hearing misinformation about physicians profiting from COVID diagnoses circulating in the news.

A Story Worth Hearing in Full

Sarah's experience across Alabama, Nevada, and California illustrates something physicians don't always talk about openly: the structural pressures of American hospital medicine, and how immigration status can compound those pressures in ways that feel almost impossible to escape. Next week, we'll get into why Sarah ultimately decided to move back to Canada and how she rediscovered her passion for medicine on this side of the border.

If you're a physician weighing a move, whether into the US system or out of it, I want to hear from you. Reach out at rob@interestingmd.com, and don't forget to subscribe so you catch part two of Sarah's story.