I think that it is a mistake to delay step 1 until after clerkships because so many of the fine details got lost with every passing day. It's like if someone took the step 1 on a monday and were told that their exam got screwed up and they have to retake the exam 10 days later. I am pretty sure that would be a nightmare scenario. the best thing to do is not fear the step 1 and take it ASAP after 2nd year, it will take a huge load off the shoulders. No matter how many patients you see, you're probably not going to see so many of the pathologies that are found in the step 1. Just pick up a copy of any path book like BRS Path and look at how many pathologies there are that are so rare that most people will never see them, yet they are the meat and potatoes of board exams. Same goes for microbio too. In my opinion, being on the wards *may* enhance your knowlege of pharm, but it will probably cause a diminishing of the details of theoretical physiology, pathology, microbio and biochemistry. The biggest pitfall in my opinion is forgetting pathology. There is SO much pathology to be learned for step 1 that if you forget a lot of it, then you will have to repeat all of your effort from the 2nd year path course just to come back to the level of path knowledge that you had at the end of 2nd year. I know some schools let the students take the step1 whenever they want, but I suspect the only reason it turns out well is that most of those school only take candidates with the highest scores,etc and those candidates are likely to study and relearn all the material again.
Either way, that is an arduous experience. BUt if you do hold off on the taking the step 1, my strong advice would be to keep reading your pathology text, or review book, or notes or whatever. Once your knowledge of path fades away, step 1 becomes a painful experience where it seems like 2-3 answers are correct for each question on the step 1 and the whole exam is spent sitting on the fence. "Well...gee...I kind of heard of monckeberg arteriosclersosis....but did that effect the tunica intima or media and did that effect the aorta or the radial artery....and was that all about atherosclerosis or was it about calcification....". Suddenly, 2-3 answers seem right for every question. To make a long story short, take Step 1 ASAP, if you delay it, then make sure to keep your knowledge of path intact.
