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The purpose of our study was to explore the effect of the physician's training level on the emergency management of common illnesses in the pediatric emergency department (ED). Our hypothesis was that physicians in training used more resources than attending physicians did in caring for pediatric patients in the ED.We retrospectively reviewed all records of patients younger than 18 years who presented to the pediatric section in ED of Taipei Veterans General Hospital between January 1, 2004, and December 31, 2005. The cohort study was composed of patients treated by a pediatric attending physician (group 1) or treated by a resident (group 2). We collected their demographic data, diagnoses, admission and revisiting rates, direct costs (including radiographic, laboratory, and medication costs per visit), and utilization data.Admission and 72-hour revisiting rates did not differ between groups. Lengths of ED stay and total, radiographic, and medication costs significantly increased with the residents (all P < 0.001). Residents ordered more radiographic (30.7% vs 23.8%, P < 0.001) and laboratory (37.2% vs 34.6%, P = 0.13) studies than attending physicians did, notably when patients had acute bronchitis and bronchiolitis or noninfectious gastroenteritis and colitis. Residents also ordered more laboratory studies in cases of pneumonia.Residents treating pediatric patients in the ED spent more time and used more medical resources than attending physicians did. An important educational objective is to improve physicians' diagnostic skills to reduce resource utilization and to improve outcomes.