[Cite as Loudin v. Radiology & Imaging Servs., Inc., 128 Ohio St.3d 555, 2011-Ohio-1817.]

L OUDIN , A PPELLEE , v . R ADIOLOGY & I MAGING S ERVICES , I NC ., ET AL ., A PPELLANTS . [Cite as Loudin v. Radiology & Imaging Servs., Inc., 128 Ohio St.3d 555, 2011-Ohio-1817.] Damages for emotional distress stemming dir ectly from a physical injury are to
be considered in a traditional medi cal-malpractice claim — Emotional distress stemming directly from a physical injury is not a basis for an independent cause of action for th e negligent infliction of emotional
distress. (No. 2010-0297 — Submitted January 18, 2011 — Decided April 20, 2011.)
A PPEAL from the Court of Appeals for Summit County, No. 24783, 185 Ohio App.3d 438, 2009-Ohio-6947.

__________________ S YLLABUS OF THE C OURT 1. Damages for emotional distress stemming directly from a physical injury are to be considered in a traditional medical-malpractice claim. 2. Emotional distress stemming directly from a physical injury is not a basis for an independent cause of action for th e negligent infliction of emotional
distress.

__________________ M C G EE B ROWN , J. {¶ 1} This is an appeal from a judgment entered by the Ninth District Court of Appeals finding that Lonna Loudin presented genuine issues of material fact that would allow her medical-malpractice claims to survive summary judgment. We affirm the judgment of th e court of appeals and hold that damages for emotional distress stemming directly from a physical injury are to beS UPREME C OURT OF O HIO

2 considered in a traditional medical-malpractice claim and that emotional distress stemming directly from a physical injury is not the basis for an independent cause of action for the negligent infliction of emotional distress. Facts and Procedural History {¶ 2} From 1997 through 2004, the appellee, Loudin, went to Reflections Breast Health Center (“Reflections”) , owned and operated by Radiology & Imaging Services, Inc. (“Radiology”), to receive yearly mammograms. All of Loudin’s mammograms during that time we re interpreted as normal. This included the mammogram conducted in 2003, which was reviewed by Dr. Richard Patterson in April of that year. {¶ 3} Loudin was persistent in monitoring herself for cancer because her husband had died of lung cancer in 1981 and she wanted to ensure early detection
and treatment if she had cancer so that the same fate would not befall her. In the spring of 2004, Loudin detected a lump in her left breast during self-examination and was referred to Reflections for a diagnostic mammogram. The films from Loudin’s May 2004 mammogram revealed a mass that was highly suggestive of malignancy. According to expert witness testimony, the mass had grown from one centimeter to approxima tely two centimeters be tween 2003 and 2004. Dr. David B. Dellinger conducted a biopsy of the mass, and the pathology report
indicated that the mass was cancerous. W ith no additional factors present, a twocentimeter cancerous mass constitutes Stage I cancer. Upon review of the pathology report of the biopsy, Dr. Joseph Koenig, Loudin’s oncologist, informed Loudin that her treatment plan would probably entail lymph-node dissection, a lumpectomy, radiation therapy, and horm one therapy, but would most likely not include chemotherapy if her lymph nodes tested negative for cancer. Dellinger and Koenig recommended the dissection of nearby lymph nodes in order to determine whether Loudin’s cancer had spre ad to other areas. Two of the eight lymph nodes dissected tested positive for can cer. This additional factor advancedJanuary Term, 2011

3 Loudin’s diagnosis to Stage IIA cancer. Loudin underwent a lumpectomy, eight rounds of chemotherapy, and six weeks of radiation therapy and began hormone therapy. At the time of her Octobe r 2005 deposition, Loudin’s cancer had not
recurred. {¶ 4} Loudin initiated this action by fili ng a complaint asserting medicalnegligence claims against the defenda nts-appellants, Radiology & Imaging Services, Inc., Radiology & Imaging Se rvices, Inc., d.b.a. Reflections Breast Health Center, and Dr . Richard D. Patterson. 1 In her first claim for relief, Loudin alleged that Radiology, as the employer and principal to its employee physicians, including Patterson, had “caused and/or contri buted to her injury.” In her second claim for relief, Loudin alleged that Pa tterson had breached the required standards of care when conducting Loudin’s regular screenings for breast cancer. In her third claim for relief, Loudi n alleged that Radiology had negligently failed to supervise Patterson. Loudin alleged injuries in the form of a delayed diagnosis of cancer, the progression of untreated carcinoma to Stage IIA breast cancer, the “loss of chance for a better outcome,” emotional distress, acute physical, mental, and emotional pain and suffering, and a loss of the ability to enjoy a normal life. {¶ 5} In her claims for medical neg ligence, respondeat superior, and negligent supervision, Loudin alleged th at the appellants had breached the required standard of care by failing to detect and commence treatment for her cancer upon examination of her 2003 mammo graphy films, which revealed a
visible one-centimeter mass. Upon being granted leave, Loudin amended her complaint on March 5, 2009, to further alle ge that the appellants’ negligence had led to the enlargement of her tumor, meta stasis to her lymph nodes, and emotional
distress from the fear of an increased chance of recurrence of cancer.

1. Loudin first filed a complaint on April 14, 2005, but voluntarily dismissed the matter without prejudice on March 16, 2007. On March 14, 2008, she refiled her complaint as permitted by R.C. 2305.19, which allowed her complaint to stay within the one-year statute of limitations applicable to medical claims under R.C. 2305.113(A).S UPREME C OURT OF O HIO

4 {¶ 6} Loudin submitted the deposition testimo ny of radiologist Dr. Jules H. Sumkin, who stated that the failure to detect her cancer in 2003 was a deviation from the applicable standard of care and that Loudin’s tumor had
increased from one centimeter to two centimeters from 2003 to 2004. Loudin also submitted the deposition testimony of an additional expert witness, Dr. Ronald Citron, who stated that to a reasonable de gree of medical certainty, the cancer would not have been present in Loudin’s lymph nodes had she been correctly diagnosed in 2003. With lymph nodes negative for cancer and a one-centimeter cancerous tumor, Loudin still would have undergone a lumpectomy, radiation therapy, and hormone therapy. Howeve r, with lymph nodes testing positive for cancer, she also had to undergo chemothe rapy. Citron testifie d that Loudin’s tenyear-survival prognosis would have been 85 percent had dete ction and treatment occurred in 2003 and that her prognosis from detection and tr eatment in 2004 was 82 percent. {¶ 7} Ultimately, the appella nts filed a motion to dismiss Loudin’s amended complaint for failure to state a claim for which relief could be granted. The appellants characterized Loudin’s comp laint as seeking recovery solely for the negligent infliction of emotional di stress. In their response to Loudin’s memorandum opposing their motion, the appella nts also argued that Loudin had
not established her medi cal-negligence claim. {¶ 8} Because both parties’ argument s relied on facts outside the pleadings, the trial court converted the ap pellants’ motion to dismiss into a motion for summary judgment. In its decision, the trial court noted that Loudin had included damages for emotional distress in her medical-malpractice claim, but had not pleaded a separate cause of action for the negligent infliction of emotional
distress. The trial court nonetheless chose to separate ly address Loudin’s request for damages for emotional distress using the analysis applied to claims for negligent infliction of emo tional distress. The trial court concluded that LoudinJanuary Term, 2011

5 was precluded from making a claim for the negligent infliction of emotional distress because such a claim would require the finder of fact to determine what portion of Loudin’s emotional distress was a ttributable to her initial diagnosis of cancer and what portion was attributable to “her understanding that the untreated cancer had metastasized, thereby changing her diagnosis for the worse.” And this type of determination, the c ourt held, was “precisely the type of issue that courts have attempted to guard against in their analyses of these types of claims.” The trial court also concluded that Loudin’s medical-negligence claim must fail because “growth and metastasis of cancer are not compensable physical injuries in Ohio.” The trial court granted summary judgment in favor of the appellants and against all claims for re lief in Loudin’s complaint. {¶ 9} The Ninth District Court of App eals reversed, holding that the growth and metastasis of cancer are compensable physical injuries and that Loudin’s medical-negligence claim should have survived summary judgment. The appellate court pointed out that Loudi n had not pleaded a separate cause of action for the negligent infliction of emoti onal distress. However, because neither party claimed that the trial court should not have addressed the issue of negligent infliction of emotional distress, the appellate court went on to analyze that issue on appeal. After a discussion of the histor y of claims for the negligent infliction of emotional distress, the appellate court focused on th is court’s explanation in
Binns v. Fredendall (1987), 32 Ohio St.3d 244, 513 N.E.2d 278, that a negligence claim involving a physical injury invokes the traditional rules of recovery, which consider emotional distress as a part of damages. The Ninth District held that Loudin’s fear of recurrence of cancer was a type of emotional injury for which Loudin could seek recovery. {¶ 10} The Ninth District concluded that the trial court’s analysis of negligent infliction of emo tional distress was not correct and ruled that Loudin’s claims for medical malpractice, and her re lated claims for respondeat superior andS UPREME C OURT OF O HIO

6 negligent supervision, should have survived summary judgment. The Ninth District affirmed the trial court’s decision regarding certain evidentiary issues, reversed the remainder of the decision, an d remanded the cause to the trial court for further proceedings. {¶ 11} The cause is before this court upon the acceptance of a discretionary appeal. Analysis Medical Negligence: Physical Injury {¶ 12} The issue before this court is whether the evidence submitted by Loudin in support of her claims for medical negligence and resulting damages was sufficient to defeat the appellants’ motion for summary judgment. {¶ 13} As with negligence claims in general, liability based on the alleged negligence of a medical professional require s proof of (1) a duty running from the defendant to the plaintiff, (2) the defendant’s breach of that duty, (3) damages sustained by the plaintiff, and (4) prox imate causation of the damages by the defendant’s breach of duty. Schirmer v. Mt. Auburn Ob stetrics & Gynecologic Assoc., Inc ., 108 Ohio St.3d 494, 2006-Ohio-942, 844 N.E.2d 1160, at ¶ 17, citing
Hester v. Dwivedi (2000), 89 Ohio St.3d 575, 578, 733 N.E.2d 1161. {¶ 14} A physician who undertakes a phys ician-patient re lationship has the duty to exercise reasonable care in diagnosing the patient’s illness and prescribing appropriate treatment. Berdyck v. Shinde (1993), 66 Ohio St.3d 573, 583, 613 N.E.2d 1014; Tracy v. Merrell Dow Pharmaceuticals, Inc. (1991), 58 Ohio St.3d 147, 150, 569 N.E.2d 875. A medical professional’s failu re to detect a condition may result in liability if the failure to detect is proven to be a proximate cause of a patient’s injury. Berdyck at 584. “Diagnosis must be regarded as important as is the treatment to be administered, for faulty diagnosis may result in treatment which is not only not correctional and curative, but is positively harmful
in character.” Willett v. Rowekamp (1938), 134 Ohio St. 285, 289, 12 O.O. 91, 16January Term, 2011

7 N.E.2d 457. Although a medical professi onal is not a warrantor of a positive result or cure, a negligent act or omission that “prolongs [a patient’s] illness, increases his suffering, or, in short, makes his condition worse than it would have been if due skill and care had been used, would, in a legal sense, constitute injury.” Craig v. Chambers (1867), 17 Ohio St. 253, 261, abrogated in part on other grounds as recognized in Cooper v. Sisters of Charity of Cincinnati, Inc

. (1971), 27 Ohio St.2d 242, 250, 56 O.O.2d 146, 272 N.E.2d 97. {¶ 15} The appellants concede that Loudi n adequately established duty and breach for purposes of summary judgment by presenting expert testimony that the appellants’ failure to detect her cancer in 2003 was a deviation from the applicable standard of care. They focus their argument on the element of damages and contend that Loudin provide d no evidence that the appellants’ failure to timely diagnose her cancer proximately caused her any physical injury. They agree with the trial court’s conclusion that “growth and metastasis of cancer are not compensable physical injuries in Ohio,” and they point out that Loudin was not cognizant of the growth of he r tumor from 2003 to 2004 and assert that
the course of treatment for her cancer would have been no less intensive had it been detected in 2003. These arguments are not well taken. {¶ 16} First, the appellants’ contention that a plaintiff must physically perceive the cancer’s progression in order for it to be a compensable injury is unfounded. The law recognizes that injuri es in medical-malpractice cases may go undetected for a long time, as evidenced by the tolling of the statute of limitations for medical-negligence claims until the pl aintiff is or should be aware of the injury. R.C. 2305.113(D). There is no requirement in Ohio that a physical injury in a traditional negligence case cause pain or otherwise manifest itself so that the plaintiff is aware of its presence and deleterious effect at all times. {¶ 17} Second, Loudin presented expert testimony that she would not have undergone an identical course of treatment had the cancer been detected inS UPREME C OURT OF O HIO

8 2003. Loudin presented expert testimony stating that chemotherapy is not administered when the lymph nodes test negative for cancer. Loudin presented further expert testimony that her lym ph nodes would have been negative for cancer in 2003. Thus, according to her experts, she would not have had to undergo eight rounds of chemotherapy but for the appellants’ failure to timely diagnose her cancer. {¶ 18} Third, the growth and metastasis of cancer are cognizable physical injuries. Loudin presented expert testimo ny that cancer is a progressive disease and that the longer it is able to progress, the more it is able to compromise additional areas of the body and increase the number of cancer cells in the body. Whether the cancer is left undiagnosed to advance to the point of necessitating the removal of an organ, a limb, a breast, or a larger lump, the destruction of additional healthy cells and increased number of cancer cells are physical injuries, not mere physical changes. 2 {¶ 19} Although tumor enlargement and involvement of the lymph nodes might not require radically different trea tment, a plaintiff need only show some slight injury for the question of damages to go to the jury. In Schultz v. Barberton
Glass Co. (1983), 4 Ohio St.3d 131, 134, 4 OBR 376, 447 N.E.2d 109, fn. 3,while comparing negligent-infliction-of-emotional-distress claims with personalinjury claims, this court explained: {¶ 20} “Courts have allowed recovery fo r emotional distress accompanied by the slightest injury. ‘When there is evidence of any injury, no matter how

2. See Tomcik v. Ohio Dept. of Rehab. & Corr . (1991), 62 Ohio Misc.2d 324, 330-331, 598 N.E.2d 900 (growth of breast cancer, requiring a mastectomy instead of a lumpectomy, constitutes injury); Moskovitz v. Mt. Sinai Med. Ctr. (1994), 69 Ohio St.3d 638, 641, 647, 635 N.E.2d 331 (facts of case show that defendants had been found negligent for failing to timely diagnose and treat cancer before it had metastasized, lead ing to amputation and death). See also Alexander v. Scheid (Ind.2000), 726 N.E.2d 272, 284 (cancer growth and destruction of healthy tissue constitute injury); Evers v. Dollinger (N.J.1984), 95 N.J. 399, 406, 471 A.2d 405 (growth of tumor constitutes physical injury); Cloys v. Turbin (Tex.Civ.App.1980), 608 S.W.2d 697, 701 (any growth of a cancerous tumor constitutes physical injury).January Term, 2011

9 slight, the mental anguish suffered by plaintiff becomes an important element in estimating the damages sustained.’ Clark Restaurant Co. v. Rau (1931), 41 Ohio App. 23, 26, 179 N.E. 196 [31 O.O. 576]. In Wolfe v. Great A & P Tea Co. (1944), 143 Ohio St. 643, 56 N.E.2d 230 [28 O.O. 520], the plaintiff was allowed to recover for mental suffering, after eating food contaminated with worms, if any physical injury was proven. See also Ward Baking Co. v. Trizzino (1928), 27 Ohio App. 475, 161 N.E. 557.” {¶ 21} When we view the evidence in a light most favorable to Loudin, we conclude that she has raised a genuine issue of material fact as to whether she would have sustained physical injuries grea ter than those that existed in 2003 but for the appellants’ negligence. Specifically, but for the failure to timely diagnose Loudin’s cancer, would her tumor have grown from one to two centimeters, would her cancer have spread to her ly mph nodes and advanced from Stage I to Stage IIA, and would she have had to unde rgo chemotherapy? The Ninth District correctly reversed the trial court’s summary-judgment decision on Loudin’s medical-negligence claim. Emotional-Distress Damages and the Negligent Infliction of Emotional Distress {¶ 22} Most, if not all, of the appellants’ argument in this appeal is predicated upon the assumption that Loudi n did not present evidence indicating that she sustained physical injuries as a result of the appellants’ negligence. Based on this assumption, the appellants a ssert that Loudin’s complaint raised a cause of action solely for the negligent in fliction of emotional distress and that the Ninth District impermissibly created a new subspecies of the cause of action in order to allow Loudin’s complaint to survive summary judgment. Loudin presented a genuine issue of material fact as to whether she sustained physical injuries as a result of the appellants’ negligence, and her complaint did not raise aS UPREME C OURT OF O HIO

10 separate cause of action for the neglig ent infliction of emotional distress; therefore appellants’ asse rtion is without merit. {¶ 23} We hold that the inclusion of damages for emotional distress in a complaint alleging negligence does not automatically transform the claim into one alleging the negligent infliction of emotional distress, nor does it automatically create a cause of action separate and distinct from the negligence claim. {¶ 24} We conclude that Loudin in cluded a claim for damages for emotional distress within the context of her medical-negligence claim and that she did not plead a separate cause of action for the negligent infliction of emotional distress. Thus, there was no negligent- infliction-of-emotional-distress claim for either the trial court or the appellate court to accept or reject, and their discussions of such a claim were unnecessary.
Conclusion {¶ 25} Viewing the evidence presented to the trial court in a light most favorable to Loudin, we hold that genuine issues of material fact exist as to whether the appellants’ delayed diagnosis deviated from the required standard of care, proximately causing physical and emo tional injuries. Therefore, we affirm the judgment of the court of appeals and remand the matter to the trial court for further proceedings. 3 Judgment affirmed.
O’C ONNOR , C.J., and P FEIFER , L UNDBERG S TRATTON , L ANZINGER , and
C UPP , JJ., concur.
O’D ONNELL , J., concurs separately.

__________________ O’D ONNELL , J., concurring.

3 The validity of Loudin’s respondeat superior and negligent-supervision claims, as well as the trial court’s evidentiary ruling, is not before this court.January Term, 2011

11 {¶ 26} I concur in the majority’s decision that emotional distress resulting from a physical injury caused by an act of medical negligence is compensable but does not give rise to an independent caus e of action on the theory of a separate tort. However, I write separately to em phasize that our holding today does not represent a departure from the current state of the law regarding the recovery of damages for emotional distress. {¶ 27} Recovery for emotional distress has evolved over the past century.
In Miller v. Baltimore & Ohio S.W. RR. Co. (1908), 78 Ohio St. 309, 85 N.E. 499, paragraph three of the syllabus, this court held that “[n]o liability exists for acts of negligence causing mere fright or shoc k, unaccompanied by contemporaneous physical injury, even though subsequent illness results, where the negligent acts complained of, are neither willful nor malicious.” {¶ 28} However, in Schultz v. Barberton Glass Co. (1983), 4 Ohio St.3d 131, 4 OBR 376, 447 N.E.2d 109, this court overruled the “impact rule” set forth
in Miller , holding that “[a] cause of action may be stated for the negligent
infliction of serious emotional distre ss without a contemporaneous physical injury.” {¶ 29} We reinforced our holding in Schultz in Paugh v. Hanks (1983), 6 Ohio St.3d 72, 6 OBR 114, 451 N.E.2d 759, holding that “[a] cause of action may be stated for the negligent infliction of serious emotional distress without the manifestation of a resulting physical injury. Proof of a resulting physical injury is admissible as evidence of the degree of emotional distress suffered.” Id. at paragraph two of the syllabus. Paugh described serious emotional distress as an “emotional injury which is both severe and debilitating” and “may be found where a reasonable person, normally c onstituted, would be unable to cope adequately with the mental distress engendered by the circumstances of the case.” Id. at paragraph 3a of the syllabus.S UPREME C OURT OF O HIO

12 {¶ 30} Nonetheless, in Binns v. Fredendall (1987), 32 Ohio St.3d 244, 513 N.E.2d 278, we distinguished Paugh , holding that “[n]egligently inflicted emotional and psychiatric injury sustained by a plaintiff who also suffers contemporaneous physical injury in a moto r vehicle accident need not be severe and debilitating to be compensable.” Id. at paragraph one of the syllabus. Thus,
Binns reaffirmed our prior understanding that “[r]ecovery for negligently inflicted emotional and psychiatric injuries accompanied by contemporaneous physical injury may include damages for mental anguish, emotional distress, anxiety, grief or loss of enjoyment of life caused by the death or injury of another, provided the plaintiff is directly involved and contem poraneously injured in the same motor
vehicle and accident with th e deceased or other injured person.” Id. at paragraph three of the syllabus. {¶ 31} Accordingly, our case law already establishes that a plaintiff who suffers a physical injury may recover for emotional distress, regardless of whether the emotional injuries are severe and debilitating. Id. at paragraphs one, two, and three of the syllabus. {¶ 32} The majority affirms the holding by the court of appeals that a delayed diagnosis of cancer can cause an attendant physical injury for which a plaintiff may seek recovery for emotional distress as an element of damages. And as the majority opinion points out, that holding is supported by authority from other jurisdictions. Majority opinion at ¶ 18, fn. 2; see also Boryla v. Pash (Colo.1998), 960 P.2d 123; Bond v. Ivanjack (D.C.App.1999), 740 A.2d 968. {¶ 33} Accordingly, I concur in the judgment affirming the judgment of the court of appeals on the basis that Lonna Loudin has raised a genuine issue of fact as to whether she sustained a physical injury as a result of a delayed diagnosis
of breast cancer. Because this case i nvolves emotional distress stemming from a physical injury, Binns controls. Thus, if Loudin proves at trial that appellants committed professional negligence that resulted in a physical injury that causedJanuary Term, 2011

13 her emotional distress, then pursuant to Binns , she may recover damages for
resultant emotional distress. {¶ 34} For these reasons, I agree that emotional distress resulting from a physical injury caused by medical negligence is compensable but does not give rise to an independent cause of action. Thus, I concur in the judgment affirming the court of appeals.

__________________ Scanlon & Elliott, Lawrence J. S canlon, and Michael J. Elliott, for appellee. Roetzel & Andress, L.P.A., Douglas G. Leak, and Stacy R. Delgros, for appellants. Melissa R. Lipchak, urging affirmance on behalf of amicus curiae, Ohio
Association for Justice.

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