This article discusses the key lessons that can be learned from a longitudinal study of the undergraduate experience of English-medium university education in Hong Kong. Data were derived from 137 semistructured interviews with 28 participants from different societal, educational and disciplinary backgrounds over three years. Each of the six rounds of interviews focused on a particular aspect of university life and study. The interviews revealed that the participants experienced an array of challenges when studying in English, including comprehending specialist vocabulary, understanding unfamiliar accents, grasping the purpose and structure of lectures, processing visual aids and planning major assignments. The article proposes a number of strategies to negate or mitigate these problems. The findings indicate that the major factor influencing student adjustment to higher education is their secondaryschool teaching medium: unlike their counterparts from Englishmedium backgrounds, students from Chinese-medium schools found the transition to university extremely taxing. The findings also suggest that content-area professors take little or no account of English skills when assessing students' assignments, which raises doubts as to whether university English courses serve any useful purpose at all.