Medical life

The great psychoanalyst and sex therapist Wilhelm Reich is reputed to have said on his deathbed, in response to a visitor who admonished him over some aspect of his lifestyle: "Could, could, should, should – fucking expectations!"

I have no idea if the anecdote is true but it is easy to identify with the sentiment. Expectations shape our lives – but do they enhance or diminish us? Everyone has an anecdote about defying doctors' expectations – Stephen Hawking was given a couple of years to live at 21 – and this month celebrated his 70th birthday.

Medics who deal in deadly diseases deliberately set their expectations low so they can be defied. At least that is my impression. A relative given a year to live in November 2010, who 15 months on is better than ever, is just the latest to have outlived his predicted time.

But last week I heard a mother whose son was diagnosed with schizophrenia at 16 complain that, after a sympathetic psychiatric nurse had given her hope, an insensitive GP had warned of the "horrendous" future he faced with a lifelong chronic illness in which he would inevitably spiral downwards. "It was so difficult to hang on to the hope the nurse had given me," she said.

It is fashionable these days to worry about excessive expectations. Thirtysomething women searching for a mate are advised to give up on Mr Right and settle instead for Mr Goodenough. Thomas Plante, writing in Psychology Today, suggested many depression sufferers were victims of the"I could have done better" style of thinking, and asked "What is a good enough life?"

Yet we know where expectations are low, performance suffers. Posting the names of university entrants prominently at a school serves as a spur to those who come after and to those who teach them. People will differ over what is excessive and what is realistic when it comes to setting expectations. But in health they too often fall short. As Atul Gawande, the surgeon and author, has observed we cannot all excel – someone has to be average. It is not being average that's the problem but settling for it.