Chainsaw! Run at them with the chainsaw! *evil insane laugh*
I'm having a hard time believing some of the people say they're playing it on Ultra Quality. In some interviews from the id folks, Ultra Quality is really made for videocards with 512MB RAM onboard, not system ram. Then again I switched to ATI and this game bites the big one when it comes to having a Radeon under the hood without tweaking.
I'm running it at medium Quality, 1024X768, all options enabled except for Antialiasing, but I have turned shadows off and it's helped marginally. My core settings in the Catalyst Control panel are set to "balanced" quality, cept that I make TruForm be enabled by application prefrence. Everything else is high quality.
30 fps average, on a Radeon 9800 Pro, ATI Catalyst 4.8's with Cat 4.9 beta OpenGL Library installed.