I'll start a hand fellowship in August.
My primary reason for choosing hand over spine would have to be lack of interest in spine - I cannot get excited about the surgery, examining patients, looking at spine MRIs, back pain, etc.
Second but very important is the fact that it seems almost depressingly difficult to quickly have the type of practice you want very soon after getting out of fellowship. For instance, with total joints, you deal with revision disasters for several years until you're churning out 8-13 primary joints two days a week with two ORs running each day, PA rounding and educating patients and taking phone calls, etc.
For me, it seemed like my ideal practice was a shorter distance away with hand/upper extremity surgery than with most other fields.
Obviously there are some dream jobs out there just waiting for the right guy, but those are the exception, I believe.
What will your professional life look like 2, 5, 10 years out from fellowship? If you can't see that far ahead, you'd better decide based purely on academic interest.
The breadth of patients and practice attracts me to hand surgery. Not all spine surgeons will end up treating fractures and certainly few will operate on adults and children, but this is not true for hand surgeons.
Think about your handful of specialty-specific nightmare patients/cases - for hand surgery it would be something like a multi-finger replant at 3AM, or a smashed open hand, or the middle aged lady with a hyphenated last name, two ex-husbands and "pain everywhere". The spine surgeon might be operating on the same middle-aged lady, but I'd take a hand surgery complication over a spine complication any day.
A large part of residents' attraction to any field is their exposure to the surgeons' practices during residency. The spine surgeons in Cleveland at Case have a great practice and several Case residents do spine each year after seeing them in action. I guarantee you that if you are just exposed to one lone spine guy who is immersed in the socialized world of academic medicine in an inefficient practice, you'll never do that fellowship unless you're inclined that way academically anyway.
