Of the 103 respondents (17%), 72% were program directors; 61% were men. Nearly all (90%) reported "some" or "a lot" of pressure to write a positive letter; 22% reported never writing negative letters; and nearly half (43%) feared legal repercussions for writing a negative letter. One-third (33%) reported they have omitted or would omit an area of concern; 30% reported they would specifically indicate a resident's weak technical or clinical skills, whereas 50% reported they would "hint at it." Of those remaining, 20% reported they would not indicate the weakness, with a higher percentage of men indicating they were likely to omit the weakness (N=16, 25% men; N=4, 10% women). Similarly, 35% (N=36) reported that they would indicate poor interpersonal skills, with half (51%, N=52) hinting at it, and 14% omitting the weakness; no gender differences were identified. When reading LOR, nearly half (44%) reported difficulty deciphering resident competency and interpreting LOR (45%) "most of the time." When asked to compare, the majority (68%) reported that personality characteristics were more important than technical/clinical skills, whereas 32% reported the opposite. A letter omitting descriptions of technical or clinical skills was interpreted as negative by 75%; the remaining 25% indicated "it depends." When asked "How important is personal information about the applicant in the LOR?" nearly half (44%) indicated "important," and 20% indicated "very important." Half (50%) interpreted LOR negatively when personality characteristics were omitted, whereas nearly all the remaining respondents (45%) indicated "it depends." When asked if writer bias was considered when reading LOR, three-quarters (75%) responded positively. Over half (55%) indicated that letter length had "hidden meaning." Written comments indicated that shorter letters were interpreted as more negative; examples included "short letters indicate poor candidates," and "short letters always raise concern about why there was so little to say."