The study explores the challenges and strategies of Saudi medical students in achieving accuracy of medical terminology in English academic writing in English-in-Education (EMI). Participants were 15 first-year medical students on an English academic writing course, data were collected through semi-structured interviews and observations in two classrooms. The data were analyzed by reflexive thematic analysis. Students find the accuracy of medical terminology a major challenge when writing medical topics in English. To cope, they use strategies such as developing ideas through Arabic, translating to clarify concepts, checking terminology step by step, and checking with partners before final phrases. Course expectations, feedback, and norms of participation influence whether strategies remain private (eg, personal notes or peer interaction) or public. Findings highlight the importance of validating terminology for disciplinary competence and the value of instruction and feedback to systematize this process.