Played another couple hours. Having a really hard time getting the mouse right but I think I got it now. V-synch forced on, shadows on high rather than ultra, mouse tweaked in ini file to remove smoothing and up sensitivity.
Anyway, I noticed a ton of old engine issues are still there. For example an enemy spawned in so far away that a story segment with him was missed because he was dead before I got there. That used to happen in previous Bethesda games too. Also the LOD pop-in is still pretty obvious when you're in a big flat area.
Loving the game though. It looks wonderful, the UI is fine if you can use a keyboard and mouse at the same time, the visual design is a million times more interesting than Oblivion's and the writing is much improved as well.