This project examined academic reading in two contrasting English as a medium of instruction (EMI) university settings in Nepal and Sweden and the unique challenges facing students who are studying in a language other than their primary language. The motivation for the project was to explore the role of high-stakes testing in EMI contexts and the implications for the design of the TOEFL iBT test. We employed a sequential mixed-methods approach to gather substantive and authentic qualitative data from stakeholders immersed in EMI settings. A small sample of students (Nepal = 19, Sweden = nine) were asked to complete reading logs over a period of 3 weeks so we could determine the types of texts and reading load associated with diverse EMI settings. Additionally, a larger cohort of students from each setting (Nepal = 69, Sweden = 60) completed questionnaires examining academic reading demands, reading skills, and practices. Students who completed the questionnaires also completed the reading section of the TOEFL iBT test. The same students also completed a TOEFL family of tests suitability questionnaire so we could consider the suitability of the TOEFL iBT test for EMI contexts. Following test completion, a series of semistructured interviews (Nepal = 21, Sweden = 23) focused more closely on students’ perspectives of reading demands in their academic contexts and the suitability of the reading section of the TOEFL iBT test to make claims about readiness to study in EMI contexts. Our findings revealed that different EMI contexts have different standards of high and low academic reading proficiency and that these differences may occur due to differences in educational experiences of the respective cohorts. The findings offer important new insights into academic reading and assessment in EMI contexts. Students in EMI contexts are sensitive to violations of expectations regarding test-taking experiences (face validity). The study has implications for the design of test tasks, which should consider local, contextual varieties of English.