BOOK REVIEW : An Rx for Reforms in Medicine : MEDICINE AT THE CROSSROADS <i> by Melvin Konner</i> Pantheon: $23; 250 pages

Who is happy with American medicine?

Not uninsured patients who vent their frustration with bullets in overcrowded emergency rooms. Not businessmen who undergo unnecessary procedures because surgeons know they can be coaxed into paying for them. And certainly not doctors who are quitting their profession in unprecedented numbers, fed up with the hassle of paperwork, the inefficiency of defensive medicine and, above all, the distrust and hostility of patients.

In “Medicine at the Crossroads,” Melvin Konner travels abroad and at home, seeking solutions to these problems from doctors, medical school deans, nurses and social workers.

Eventually he asks, “If the people who run the system don’t like it, why don’t they change it?” Konner, who is an anthropologist with a medical degree from Harvard, replies that the answer is anthropological: No one in this social hierarchy, he observes, can willfully counteract the forces that make things work--whether these forces be the cultural traditions passed on in medical training, the advances of science or the interests of all those accustomed to getting a particular piece of the pie.

Konner uses his formidable analytical skills to focus on what he sees as critical issues, including medical education, the aging of the population, the plight of the mentally ill, the role of AIDS in energizing the health-care system and the danger of betting on magic bullets in the form of new drugs, genetic engineering or high-tech machinery.

Writing with passion, Konner reinforces his descriptions of real people in rough situations with enough statistical data to be convincing but never numbing. Above all he denounces “the insurance ‘industry,’ a vast parasitic bureaucracy of 1,500 private businesses whose tentacles reach deep into the lives of patients and whose burdensome activities demoralize doctors and drive them out of medicine.” But to change the system, Konner believes we must rethink our priorities. Beyond the greed of the aforementioned lawyers, doctors and insurance companies, there is a chasm of distrust between doctors and patients.

Konner blames this on the culture of medical education, which encourages doctors from the day they receive their cadaver as new medical students to distance themselves from their patients. He chastises educators for ignoring the medieval aphorism that “the goals of medicine are to cure sometimes, to relieve often and to comfort always.”

The public, too, bears its share of the responsibility for the current mess. They hold doctors hostage to a standard of perfection that is simply not humanly possible. Like everyone else, doctors get tired and occasionally make mistakes, for which Konner argues the patient should be compensated, as they are in Sweden, but not at the price of bankrupting the doctor and the system.

These unrealistic standards, Konner explains, come from an excessive faith in technology and a refusal to accept the inevitability of death.

He reminds us of how other cultures treat those who are dying. Both Bushmen and Eskimo care for their elderly until they can no longer move with the tribe. At that time, “and only as a last resort, an old person might separate from the rest of the group and quietly succumb to exposure and weakness in the familiar bush country where he or she had spent a lifetime.”

Konner offers several descriptions of new approaches to medicine, including the suggestion of Dr. Julian Tudor-Hart in England, who proposes a “patient-as-colleague-model” to forge a bond between healer and healed. Another idea is Dr. Gerald Weissman’s at New York University; he suggests a national health corps built on the existing VA hospitals, American Indian reservation physicians and Public Health Service doctors.

While we can all benefit from Konner’s suggestion, it would be especially useful if those in Hillary Rodham Clinton’s task force pay special attention to what Konner has to say in “Medicine at the Crossroads.”