Historically, followers have been positioned as subordinate actors, defined more by compliance than by contribution. In contrast, leadership roles are associated with an assumption of power, which may be formal, positional, and at times authoritative. This dichotomy is misleading. Many individuals in formal leadership roles experience constraints in their ability to effect change, as authority alone does not reliably translate into influence. Conversely, we all know individuals who are “not in charge” but seem adept at moving people and projects through influence alone.

For the purposes of this paper, we define influence as the ability to create movement of ideas, people, teams, and systems toward a shared purpose. In this context, followers and the practice of followership gain important clarity. That’s because our experience has led us to believe that it’s not the title that influences, it’s the person. Followership then represents a form of leadership exercised by individuals who hold responsibility without formal authority and who use their influence to advance organizational goals, execute a leader’s vision, and contribute to collective success.

Yet even this definition leaves an important challenge unresolved. The term followership itself carries a powerful cultural connotation. For many, it evokes images of compliance, deference, and dependence on the decisions of those in leadership positions. Regardless of how the concept is defined academically, the language suggests that influence flows primarily from leaders to followers, rather than recognizing the reciprocal nature of organizational change.

Even among those familiar with its principles, there is persistent resistance to adopting the identity of “follower.” This resistance is not rooted in the intellectual substance of followership, but the perceived absence of power. Followership warrants reframing as a locus of individual power and influence, rather than a passive act of following the leader.

As a result, we advocate for a shift in language from followership to undercover leadership.

This terminology better reflects the reality that individuals throughout an organization possess the capacity to influence outcomes regardless of their title or formal authority.

Undercover leaders are not passive participants in someone else’s vision. They are active contributors who shape culture, improve systems, challenge assumptions, build trust, and move teams toward shared goals through their daily actions and interactions.

This distinction is particularly important in health care. Most physicians, nurses, and health care professionals enter the profession because they want to make a difference.

They see themselves as problem-solvers, advocates, and agents of positive change. When leadership is framed as something reserved for those with formal authority, many conclude that meaningful influence is similarly restricted. The result is a false dichotomy in which individuals are either leaders who create change or followers who simply support it. The reality is far different. Health care organizations are complex adaptive systems in which culture, quality, safety, and performance are shaped by countless interactions occurring far from executive offices and boardrooms. The decisions made by frontline clinicians, the conversations that occur between colleagues, the willingness to speak up, offer feedback, mentor others, challenge harmful norms, and advocate for improvement all exert influence on the system.

These are acts of leadership, even when they occur without authority.

This perspective is especially relevant at a time when health care faces unprecedented challenges. Burnout, workforce shortages, moral injury, and declining trust have exposed the limitations of relying solely on positional leadership to drive transformation. Sustainable change cannot rest on the shoulders of a few individuals with titles. It requires the engagement of thousands of professionals who recognize their own capacity to influence the environments in which they work.

By updating our understanding of followership as undercover leadership, we shift the focus from position to contribution. We remind individuals that leadership is not merely a role to occupy but a responsibility to influence. In doing so, we expand the number of people who see themselves as capable of improving culture, advancing mission, and creating meaningful change within their organizations.

Undercover leadership: a shift from followership

At its core, effective followership optimizes influence rather than authority. The behaviors that generate engagement, attitude, and influence often go under-recognized because they occur outside formal leadership structures. Yet these are the same behaviors that shape teams, culture, and everyday experiences. They are the foundation of undercover leadership: leadership practiced without reliance on title or position.

Engagement reflects the degree to which an individual invests cognitively, emotionally, and physically in their work. The distinction between task completion driven by obligation versus commitment is readily observable and consequential. Presence, active listening, and constructive challenging are the necessary elements of effective engagement.

Attitude shapes the climate of teams. Individuals who approach work with a constructive and positive mindset contribute to task execution, and to the psychological environment in which others operate. Like engagement, attitude is not fixed. It is shaped by three behavioral attributes within an individual’s control: self-regulation, accountability, and ownership.

Influence, perhaps the most consequential domain, emerges from the integration of engagement and attitude. Individuals who are committed and constructive exert a disproportionate impact on team dynamics. They facilitate coordination, reduce friction, and shape norms. The marks of influence mastery are the individuals who know how to seek common ground, consistently show up for their teams, and provide the type of optimism that is grounded in reality but keeps hope alive.

In this model, influence is not about charisma or manipulation. This form of influence creates trust, strengthens teams, and shapes culture independent of title or authority.

Over time, individuals who consistently demonstrate the behaviors associated with undercover leadership often become the people others naturally choose to follow.

As such, health care organizations would benefit from explicitly developing the capacity for undercover leadership. Shifting the narrative from “leader versus follower” to “authority versus influence” creates space to recognize and cultivate the skills that drive team performance.

This implication is simple yet demanding. Not everyone holds authority, but everyone can exercise influence and make an impact. The question is no longer whether individuals are leading or following, but how influence is used by undercover leaders as a complementary tool to the authority granted to formal leaders.

The shift transforms leadership from a scarce resource into a shared responsibility. Formal leaders retain authority, expertise, and accountability, but the work of shaping culture, driving improvement, and creating results no longer rests on their shoulders alone. When individuals recognize themselves as undercover leaders, organizations unlock a far larger source of influence than any hierarchy can provide.

Lauren Weber, MD, is a cardiologist and co-founder and director, All Levels Leadership. Jess Bunin, MD, is a critical care physician and cofounder, All Levels Leadership.

All Levels Leadership is a physician-led health care leadership development firm dedicated to empowering professionals across the career spectrum. With a foundation in clinical care, academia, and governance, the organization delivers customized coaching, mentorship, and training programs that foster resilience, well-being, and leadership excellence. All Levels Leadership has presented nationally and internationally at events hosted by the American College of Physicians, the International Conference on Residency Education, and the Society of Critical Care Medicine. Committed to advancing inclusive and transparent cultures, the firm helps individuals and teams lead with clarity and purpose. Explore their programs and services at alllevelsleadership.com, and connect with them on LinkedIn. To read more about their work, including recent podcasts and publications, visit their podcasts and publications.