This study examines the practice of Chinese medicine in Southern California by practitioners trained, in English, in local schools of Chinese or "oriental" medicine. It uses a mixed methods approach to examine the influences of both culture and interaction in the ways that the practitioners construct their professional identities and their relationships with patients. Using a combination of conversation analysis, ethnography, and cultural sociology, this study describes how acupuncturists present themselves and their office environments, how acupuncture visits are structured, and how practitioners interact with patients. Each of these features of the Chinese medicine visits, further, are shown to be in certain important ways to be responsive to the American context, in particular to biomedical dominance. The ways that acupuncturists manage biomedical dominance tend to highlight the positive qualities – such as the close patient-practitioner relationships – of Chinese medicine within the context of a cultural discourse that conceptualizes Chinese medicine in opposition to biomedicine. But, the fact of referencing biomedicine, as well as the way biomedical references invoke authority and legitimacy, serves to reproduce the unequal relationship between Chinese medicine and biomedicine. This examination of how acupuncturists manage their professional identities and relationships with patients illuminates some of the dynamics and consequences of hierarchical medical pluralism. It also shows some of the ways that the practice of Chinese medicine has been adapted to the American context and adds to the growing body of work showing contemporary Chinese medicine to be a diverse and dynamic field of knowledge and practice.